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      Diabetic retinopathy screening during the coronavirus disease 2019 pandemic

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          To the Editor: The current focus on the coronavirus disease 2019 (COVID-19) pandemic have invariably led to some compromises in medical care [1] and the curtailing of health services, including screening programs. This is reflected by the recent recommendation of the Royal College of Ophthalmologists on postponing routine diabetic retinopathy (DR) screening of patients with diabetes mellitus []. Although it helps prevent visual loss [2], we understand that postponing DR screening may be necessary when facing severe shortages in staff, personal protective equipment, and escalating new infections. However, in areas with effective infection control and low community transmission, we believe it can be continued safely, especially when incorporating advances in telemedicine. Such is the case with DR screening in Hong Kong. Our department had previously played a leading role in researches [3] which led to the establishment of universal DR screening in Hong Kong since 2014. The current program involves scheduling patients with diabetes for DR screening every 1–2 years (depending on coexisting risk factors). During screening, patients’ visual acuity and digital fundal photos are uploaded to a secure, central server. The uploaded images are graded remotely at secure workstations according to a standardized protocol [4]. Patients with sight-threatening stages of DR are referred to ophthalmologists for further management. The Department of Family Medicine and Primary Healthcare (FM&PHC) of Hong Kong West Cluster, as with other FM&PHC departments throughout Hong Kong, have continued DR screening throughout this period. As the causative agent for COVID-19 can be present in ocular secretions [5], additional measures have been adopted to reduce transmission risk, including: Screening of all visitors for: body temperature for fever, history of respiratory symptoms, recent overseas travel, and possible contact or exposure to COVID-19 cases. Those screened positive had their screening postponed (if patients) and referred to designated hospitals for suspected cases. Universal face-covering with surgical or N95 masks by staff and all visitors. Patients arriving without surgical masks were provided one. Protective plastic shields installed on all slit-lamps, which are used during eye examinations. Number of bookings reduced to avoid overcrowding within the clinics. As bookings were intentionally reduced since February 2020, the number of attendances decreased compared with the same period in 2019 (Table 1). Comparing the first quarter of 2019 and 2020, bookings and attendance decreased by 24.0% and 27.6%, respectively, with a small rise in default rate from 15.1% to 19.1% (Fig. 1). The default rate was especially high for February 2020, when there was widespread fear of acquiring COVID-19 by many patients at the time. It has since improved slightly for March 2020. As of 12th April 2020, there have been no reported cases of COVID-19 infection among our clinical staff, nor any patients who underwent DR screening during this period. Table 1 Number of bookings, attendances, and defaults for January, February, and March of 2019 and 2020. Jan-19 Feb-19 Mar-19 Jan-20 Feb-20 Mar-20 Bookings 777 567 819 550 489 605 Attendances 663 477 696 469 368 493 Defaulted 114 90 123 81 121 112 Default rate % 14.7 15.9 15.0 14.7 24.7 18.5 Fig. 1 First quarter data for 2019 and 2020. Total bookings, attendances, and defaults for the first quarter of 2019 (1Q 2019) and 2020 (1Q 2020). We believe it is safe and worthwhile, when resources and infection control measures are available, to continue with DR screening, especially for patients with poor diabetic control, in view of the likely protracted course of the current COVID-19 outbreak.

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          Most cited references 3

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          Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Early Treatment Diabetic Retinopathy Study Research Group.

          The Early Treatment Diabetic Retinopathy Study (ETDRS) enrolled 3711 patients with mild-to-severe nonproliferative or early proliferative diabetic retinopathy in both eyes. One eye of each patient was assigned randomly to early photocoagulation and the other to deferral of photocoagulation. Follow-up examinations were scheduled at least every 4 months and photocoagulation was initiated in eyes assigned to deferral as soon as high-risk proliferative retinopathy was detected. Eyes selected for early photocoagulation received one of four different combinations of scatter (panretinal) and focal treatment. This early treatment, compared with deferral of photocoagulation, was associated with a small reduction in the incidence of severe visual loss (visual acuity less than 5/200 at two consecutive visits), but 5-year rates were low in both the early treatment and deferral groups (2.6% and 3.7%, respectively). Adverse effects of scatter photocoagulation on visual acuity and visual field also were observed. These adverse effects were most evident in the months immediately following treatment and were less in eyes assigned to less extensive scatter photocoagulation. Provided careful follow-up can be maintained, scatter photocoagulation is not recommended for eyes with mild or moderate nonproliferative diabetic retinopathy. When retinopathy is more severe, scatter photocoagulation should be considered and usually should not be delayed if the eye has reached the high-risk proliferative stage. The ETDRS results demonstrate that, for eyes with macular edema, focal photocoagulation is effective in reducing the risk of moderate visual loss but that scatter photocoagulation is not. Focal treatment also increases the chance of visual improvement, decreases the frequency of persistent macular edema, and causes only minor visual field losses. Focal treatment should be considered for eyes with macular edema that involves or threatens the center of the macula.
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            Screening for Diabetic Retinopathy with or without a Copayment in a Randomized Controlled Trial: Influence of the Inverse Care Law

            To examine whether the inverse care law operates in a screening program for diabetic retinopathy (DR) based on fee for service in Hong Kong.
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              The scandals of covid-19

               Kamran Abbasi (2020)

                Author and article information

                Eye (Lond)
                Eye (Lond)
                Nature Publishing Group UK (London )
                4 May 2020
                : 1-2
                [1 ]ISNI 0000000121742757, GRID grid.194645.b, Department of Ophthalmology, , University of Hong Kong, ; Hong Kong, Hong Kong
                [2 ]ISNI 0000 0004 1764 4320, GRID grid.414370.5, Department of Family Health and Primary Healthcare, , Hospital Authority Hong Kong West Cluster, ; Hong Kong, Hong Kong
                © The Royal College of Ophthalmologists 2020

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.


                Vision sciences

                public health, health services


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