LETTERSenvironment described. It seems likely toReferencesmeet the above criteria and its long-LETTERSterm performance can be assessed in

1. Taylor R (on behalf of the British due course.Diabetic Association Mobile Retinal The retinal screening arrangements forScreening Group). Practical com- any given District must suit local circum-munity screening for diabetic retino- stances and mesh well with the rest of

Alternatives to the Retinal Camera pathy using the mobile retinal camera: the local diabetes care system. Thesereport of a 12-centre study. Diabetic important points are emphasized in aMed 1996; 13: 946–952. document about to be circulated byWe read with interest the paper by 2. Leese GP, Tesfaye S, Dengler-Harles the BDA.2 This comprises two practicalProfessor Roy Taylor1 (on behalf of the M, Laws F, Clark DI, Gill GV, MacFar- sections, one on screening methods basedBDA Mobile Retinal Screening Group), lane IA. Screening for diabetic eye on optometrists and one on screeningdescribing the results of a multi-centre disease by optometrists using slit methods based on retinal photography.community screening programme for dia- lamps. J Roy Coll Phys 1997; 31: The intention is to provide informationbetic retinopathy using the Mobile Retinal 65–69. and hence to allow appropriate decisionsCamera. Unfortunately, this paper did not 3. Greenwood RH. Population-based to be made by physicians in Districtsdiscuss in detail alternative screening screening for diabetic retinopathy: a which do not yet have a formalizedmethods, in particular slit-lamp biomicros- promising start. Diabetic Med 1996; screening programme. The documentcopy by optometrists.2 The accompanying 13: 925–926. emphasizes the important bottom line:editorial by Dr Richard Greenwood3 (also 4. Taylor R, Lovelock L, Tunbridge every screening programme must havea member of the BDA Mobile Retinal WMG, Alberti KGMM, Brackenbridge ongoing quality control with around 5 %Screening Group) perhaps not surprisingly RG, Stephenson P, Young E. Compari- being examined by a gold standardcomes out in favour of community screen- son of non-mydriatic retinal photogra- method. Our patients will judge us uponing for diabetic retinopathy by Mobile phy with ophthalmoscopy in 2159 what we achieve for them, not whichRetinal Camera. Again, we believe that Dr patients: mobile retinal camera study. method we use.Greenwood has not adequately discussed Br Med J 1990; 301: 1243–1247.valid alternatives to the retinal camera. 5. Gatling W, Howie AJ, Hill RD. An R. TaylorWe all are aware that universal examin- optical-practice-based diabetic eye Royal Victoria Infirmary,ation by a consultant ophthalmologist (the screening programme. Diabetic Med Newcastle upon Tyne‘Gold Standard’) is logistically impossible 1995; 12: 531–536. NE1 4LPand that ophthalmoscopy in a diabetic

UKclinic situation is unreliable. Screeningby ophthalmic opticians in the community Reply from R. Taylorappears successful in some areas,4,5 butit is dependent upon expertise and tech- The critical imperative in screening for Referencesnique.

diabetic retinopathy is that it should beIn North Liverpool we have used traineddone. Naturally one would wish that 1. Taylor R. Practical retinal screeninghospital-based optometrists for retinalit should be done well. However, the using the mobile retinal camera:screening in our diabetic patients, usingyawning gap in outcome between no report of a 12 centre study. Diabetica 78-dioptres Volk lens with slit lamp.2coherent screening and screening done Med 1996; 13: 946–952.Compared with consultant ophthalmol-by any reasonable method must be 2. British Diabetic Association. Diabeticogist screening, a sensitivity of 97 % andacknowledged. Much emotion is Retinopathy Screening: Practicalspecificity of 92 % was observed. Lessexpended upon attacks and defences of Guidance. London: BDA, 1997.than 1 % of patients were referred to theparticular techniques. Our recent paperophthalmic clinic because of poor retinalreporting outcomes of a variety of photo-visualization. An important additionalgraphic screening methods in a wide Reply from R. Greenwoodpoint is that patients benefited from visual variety of different geographical areasacuity testing prior to dilatation, glaucoma restricted itself to discussion of data Drs Gill and Macfarlane have misinter-screening, and assessment of cataracts. acquired over long periods of time in preted my editorial. I did not come outPatients with urgent or serious problemsroutine clinical practice.1 It would have in favour of community screening forbenefit greatly as they are referred to andbeen presumptious to have launched a diabetic retinopathy by the Mobile Retinalseen by the ophthalmology staff at thedetailed critique of other possible tech- Camera. While this approach seems tosame visit. Compared with the BDAniques. The Introduction to the paper work well in our own large rural districtGroup’s series, the cost of individualpointed out: ‘Any one of these methods and in most other districts in the BDAscreening by optometrists was similar, butcan perform well in the hands of enthusi- sponsored scheme, I acknowledged thatthe cost of detecting significant retino-asts. The challenge remains to establish other approaches including screening bypathy was cheaper.1,2

screening systems which are effective, optometrists may be more appropriate inThere are therefore clearly valid (and,robust and cost-efficient in the circum- other districts depending on local facili-from our study, possibly better) alterna-stances of each health district.’ ties, organization and enthusiasm. Thetives to the Mobile Retinal Camera. Uni-

The data reported in the paper demon- Liverpool optometrist scheme1 is evidentlyversal and uncritical acceptance of cam- strated that these criteria had been met successful and it is interesting to note thatera-based systems of retinal screening are with respect to the screening methods within the same city there is also anot justified at present and may divert used in the 12 health districts. There successful camera-based scheme.2 Otherattention and resources away from bet- was no implication that camera-based optometrist and camera schemes haveter methods.programmes for retinal screening should proved to be less effective.3 Nationally

there seems to be considerable variationbe either universally or uncriticallyadopted. The retinal screening techniqueG. Gill and I. MacFarlane in performance with either technique

and widespread uncertainty about optimalDiabetes Centre, Walton Hospital, Rice outlined by Drs Gill and MacFarlanesounds very good for the particular urbanLane, Liverpool L9 1AE operational policies.

622 CCC 0742–3071/97/070622–02$17.50 1997 by John Wiley & Sons, Ltd. DIABETIC MEDICINE, 1997; 14: 622–623