Shahid Ahsan, et al
diabetics3. The most recent survey of diabetes4 in
Pakistan reported 26.3% prevalence of diabetes, of
which 19.2% had known diabetes and 7.1% were
diagnosed on screening. In order to prevent
progression of DR to STDR leading to gross impaired
vision, at least all the known diabetics should undergo
annual DR screening as per recommendations5,6. It is
commonly observed in clinical practice that many
individuals having diabetes in Pakistan present with
varying degree of retinopathy and visual deterioration
on their first presentation, jeopardizing the final visual
outcome. This state of affairs may arise either from
failure to detect retinopathy at an appropriate stage or
a delay in treatment7. Diversity of the tools and
operators has resulted in marked variations in the
results attributed not only to modality by which
screening was performed but to the expertise of the
health care provider. Developed countries have their
own screening methodologies8. Developing countries
have to find out screening methods which are not only
feasible, cost-effective but meet international
standards of > 80% sensitivity, and > 95% specificity9.
(Standards set by British Diabetic Association (BDA).
Though Pakistan has an elaborative network of health
care facilities at primary, secondary and tertiary care
level, a proper functioning referral system is lacking10.
This situation is further accentuated by shortage of
trained and qualified ophthalmologists. Currently,
country has nearly 30,000 qualified registered
ophthalmologists against the required number of
100,00011. Thus mandatory screening of all patients by
ophthalmologist as per recommended guidelines is out
of questions for a long time to come. Non-Mydriatic
fundus camera (NMFC) has been recommended as
useful tool for mass screening12. It can be used at
primary/secondary level by trained paramedics to
lessen the burden on ophthalmologist and meet the
required criteria. The cost and maintenance prevents
its use in resource strained country like ours. Direct
ophthalmoscopy in the hands of well-trained
optometrist might be a cheaper method. A study
carried in a tertiary care diabetes center reported
sensitivity of 60% and specificity of 76%13. The
findings of this study though did not validate the use
of direct ophthalmoscopy by Diabetologist; authors
however advocated its use and suggested to invest on
the training of health care providers till financial
resources allow shifting to the modern technology like
fundus camera. In another study from Lahore, ―direct
ophthalmoscopy‖ in the hands of ophthalmologist
considering as gold standard was compared to "Arc
light‖, concluded that ―Arc light‖ can be used as a
replacement of Ophthalmoscope for diagnosing DR or
other diseases as shown by the sensitivity and
specificity analysis in this study‖. The researcher
found optometrist almost equal to ophthalmologist in
diagnosis of DR with ophthalmoscope as well as ―Arc
light14 Apart from this study, sensitivity and specificity
of ―direct ophthalmoscope‖ in the hands of optometrist
has been scarcely studied in Pakistan. Present study
was conducted with two objectives. First, to validate
the findings of an earlier study using NMFC by
optometrist. Second, to find out the diagnostic
accuracy of direct ophthalmoscopy in the hands of
optometrist. The standard reference in the present
study was bio-microscopy with 90D fundus lens by
ophthalmologist.
MATERIAL AND METHODS
This was a comparative cross sectional study with
non-probability, purposive sampling, carried out at
diabetic eye clinic of Al Ibrahim eye hospital (AIEH).
Duration of the study was from October to December
2018. All newly registered type 2 patients with
diabetes, ≥ 40 years of age, irrespective of gender and
ethnicity and willing for eye examination with dilated
pupil were inducted whereas patients with type 1 and
gestational diabetes or patient having any other eye
disease were excluded from the study. All patients
were examined for routine basic eye examination like
refraction and best-corrected vision and entered into
database. First screening was carried by an optometrist
(Optometrist A) without dilatation of pupil. Two 45
degree retinal images one center to macula and other
center to optic disc were taken using Non Mydriatic
fundus camera (NMFC) (Cannon CR-1). The data of
fundus image was saved in the HMIS (AIEH)
database. The consent was obtained from the patient
for dilatation of pupil after informing about
transitional haziness of vision after dilatation and
confirming that patient is not driving after
examination. Tropicamide 0.1% was used for
dilatation of pupil. After full mydriasis, Optometrist
(Optometrist B) examined the fundus with direct
ophthalmoscopy and entered the data in the HMIS
(AIEH) database. The optometrists were instructed to
identify presence or other wise of the diabetic
retinopathy based on presence of hemorrhages,
exudates, blood vessel changes and macular edema.
They did not grade the retinopathy. In order to
eliminate the observer bias both optometrists were
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Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 120-124