Letters

Annual retinal photography is not an option in India

BMJ 1995; 311 doi: http://dx.doi.org/10.1136/bmj.311.7014.1230 (Published 04 November 1995) Cite this as: BMJ 1995;311:1230
  1. K J Singh,
  2. R N Misra,
  3. S Bajaj,
  4. A Malik
  1. Assistant professor of ophthalmology Professor of ophthalmology Assistant professor of endocrinology Registrar in ophthalmology MLN Medical College, Allahabad, India

    EDITOR,--Bob Ryder advocates the use of opthalmoscopy combined withretinal photography after dilatation of the pupil in screening for diabetic retinopathy.1 Differences in cost between the methods depend on the high capital cost of the camera, the cost of transporting the patient to a centre where a fundus camera is available, compliance, and the time taken to examine the patient.

    Although direct ophthalmoscopy is possible in an underdeveloped country such as India, examination of the fundus with the combined technique is not feasible because of financial constraints. Fundus cameras are available only at selected centres a rough estimate is that there is one fundus camera per 10 million population. Even some of the teaching departments of ophthalmology of medical colleges do not possess such a camera. Under these circumstances, if a fundus camera was used for screening the basic aim of providing a camera for angiography would be defeated as the workload would increase immensely, limiting the quality of treatment.

    After pharmacological dilatation of the pupils of 214 of our diabetic patients an endocrinologist and ophthalmologist concurrently looked for retinal changes on direct ophthalmoscopy; there was disagreement in only three patients (unpublished observations). Foulds et al stated that ophthalmoscopic screening by either an ophthalmologist or a diabetologist was cost effective.2 It has also been recommended that all diabetic patients should be screened annually, either by ophthalmoscopy through pharmacologically dilated pupils or by retinal photography, so that those requiring treatment are detected.3 This annual examination is not possible even in developed countries4 so cannot be expected in an underdeveloped country.

    In India the treating doctor should examine the fundus by direct ophthalmoscopy when diabetes is diagnosed. A complete check up should include an assessment of vision with a Snellen's chart and, after dilatation of the pupils, examination by direct ophthalmoscopy of the macula, disc, and remaining portion of the retina, in that order, toassess sight threatening changes. If evidence of vision <6/6 or even very early changes such as microaneurysms, dot haemorrhages, and hard exudates are found the patient should be referred to a centre where a fundus camera and laser are avilable for further management. This will reduce the burden of managing diabetic retinopathy on the doctor and the treating ophthalmologist.

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