Biennial Screening May Delay DR Treatment

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THE UK national screening committee recommends biennial eye screening for people living with diabe­tes who are considered “low risk” for diabetic retinopathy (DR). But a large U.K. study that compared annual eye screening for DR with screening every two years for DR suggests that biennial screening may cause treatment delays and possible vision loss for a proportion of those deemed low risk. Delays may also disproportionately affect some patient populations.¹

Background. The U.K. National Health Service introduced the Diabetic Eye Screening Programme in 2003, recommending annual eye screenings for people ages 12 and up with type 1 and type 2 diabetes. The goal was early detection and treatment of DR. In 2016, the recommendation for low-risk individ uals with diabetes changed from annual to every-other-year screening and was supported by evidence of safe­ty, cost-effectiveness, and the potential to reduce the number of appointments and workload (implementation of this recommendation nationally in England was delayed).

“When we started the study, two-year recall for diabetes eye screening was a proposed change, but it was not enacted,” said corresponding author John Anderson, MD, at Homerton Healthcare NHS Foundation Trust, in London, where he and colleagues run a large diabetes eye screening program. “There was limited data in peer-reviewed journals on whether this would mean a delay in the discovery of sight-threatening eye disease in some people.”

Objectives and methodology. To learn more about the impact of bien­nial versus annual screening for the detection of sight-threatening diabetic retinopathy and proliferative diabetic retinopathy, Dr. Anderson and col­leagues used 2012-2021 data from one of the largest most ethnically diverse diabetic screening programs in North East London. They tracked the eye health of 82,782 people with diabetes who had no diabetic eye disease in either eye on two previous consecutive screens.

“We did not know what the findings might be, but we felt that real-life data should be used to find out,” Dr. Ander­son said.

Findings. Biennial screening was shown to potentially delay diagnosis by one year in 56.5% of those with sight-threatening diabetic retinopathy and in 44% of those with proliferative diabetic retinopathy.

“The study showed that in a propor­tion of people who met the proposed criteria for two-year recall, the iden­tification of sight-threatening disease would be delayed by a year,” Dr. Ander­son said.

Projected diagnostic delays dispro­portionately impacted Black and South Asian individuals living with diabetes, as well as those living with diabetes who were younger than 45 and those who were older than 65 years. The results suggest significant differences in sight-threatening diabetic retinopathy rates across different ethnicities and age groups.

Disease. The highest sight-threaten­ing diabetic retinopathy rates were seen in people living with diabetes who were of Black and South Asian ethnicity; the rates were 121% and 54% higher than in White people living with diabetes, respectively.

Progression to sight-threatening diabetic retinopathy was higher in the youngest and oldest age groups. Sight-threatening diabetic retinopathy rates were also found to be higher in those with type 1 diabetes compared to people with type 2 and in females compared with males.

Health equity. The findings suggest that a biennial screening interval could negatively and disproportionately affect certain ethnic and age groups. “Dif­ferent groups within the very diverse London population would be affected unequally by the introduction of a two-year recall,” said Dr. Anderson.

Moving forward, the criteria that determines which people with diabetes should be reexamined more often to minimize age- and ethnicity-linked health inequalities needs to be reevalu­ated, said Dr. Anderson.

“We hope that our findings will be used to personalize screening pathways for population subgroups to prevent unequal health outcomes,” he said.

—Patricia Weiser, PharmD

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1 Olvera-Barrios A et al. Br J Ophthalmol. 2023;107(12):1839-1845.

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Relevant financial disclosures: Dr. Anderson—None.

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