Orthoptist and indigenous eye health coordinator in the northern territory’s top end, MADELAINE MOORE, explains how lack of funding to expand existing services has led to a pilot for orthoptic-led diabetes screening clinics.
The ophthalmology department at Palmerston Regional Hospital (PRH), a campus of Royal Darwin Hospital (RDH), is the eye hub for the Top End of the Northern Territory (NT), and it caters to a large Aboriginal and Torres Strait Islander demographic.
Diabetes mellitus affects 12% of Aboriginal and Torres Strait Islander people living in rural and remote locations and is among the leading causes of preventable blindness for this population group.¹
Screening plays a critical role in early detection and treatment of diabetic retinopathy (DR) and it is recommended that Indigenous patients with diabetes receive an annual eye check.
The Australian Government funds the Provision of Eye Health Equipment and Training (PEHET) program, with the aim of engaging remote area general practitioners, nurses and Aboriginal Health Practitioners (AHP) to screen for diabetes using a retinal camera. The rollout included installation of retinal cameras across a high number of remote primary healthcare centres.
This program has had varying levels of success across the country, however, due to the NT’s transient workforce and remote health workers’ overburdened workloads, there has been scarce uptake of this initiative in the Top End. The good news is a number of NT communities are equipped with a retinal camera.
The average diabetes screening rates across remote communities in the Top End are 33%, and the majority of these eye checks are being delivered through the Commonwealth-funded Visiting Optometrist Scheme (VOS).
The VOS program does not have further funding to increase its services, so a pilot study of orthoptic-led diabetes screening clinics was conducted. To maximise diabetic patient attendance, the clinic was delivered at the same time the diabetes educator and remote GP were visiting the clinic.
The aim of the pilot was to deliver a shorter consult and maximise the volume of patients. The work-up solely consisted of visual acuity with pinhole and undilated fundus photo using the Canon Digital Non-Mydriatic Retinal Camera. Working with the diabetes educators, the pilot aimed to recruit pre-presbyopic asymptomatic patients, who likely would not present to optometry.
The pilot included three days of service to three different communities; Palumpa, Wadeye and Nauiyu. The total number of patients who presented was 33, with the findings listed in Table 1.
Two of the three patients with DR were new detected patients. The two patients with no view were awaiting cataract surgery on the public hospital waitlist. The incidental finding was reviewed with the ophthalmologist and referred to RDH for additional investigation.
The pilot encountered similar challenges to any remote Indigenous community clinic, including a low patient attendance day due to sorry business within the community.
Another challenge included clinics without the retinal camera, which required the team to transport the portable camera, which was heavy and awkward to get in and out of the chartered flight.
The orthoptist is an appropriate candidate to deliver DR screening as they are trained to confidently detect and grade DR on fundus images, as well as recognise other abnormalities, which may be intimidating for GPs who are not experienced in eye health.
Additionally, when incidental findings do occur, the close working relationship with ophthalmologists provides an efficient review pathway. The other benefit of the pilot was the opportunity to provide capacity building to the Aboriginal Health Practitioners. The high volume and repetitive workflow made it easier to consolidate the skill.
The pilot’s main successes include reaching asymptomatic and pre-presbyopic patients who would not self-present to optometry, no need for patients to undergo dilation, capacity building, and the short duration consult with minimal wait times reducing the number of people who ‘do not wait’.
If the program proves to be a success, I believe expanding the Medicare funding item to include orthoptists will be a necessary measure to make it viable.
REFERENCE
1. National Aboriginal and Torres Strait Islander Health Survey, 2018-19 financial year, Australian Bureau of Statistics (abs.gov.au)
ABOUT THE AUTHOR: Madelaine Moore is an orthoptist and Indigenous eye health coordinator working in Royal Darwin Hospital, Northern Territory. She has a Bachelor of Health Sciences/Master of Orthoptics (La Trobe University) and a Postgraduate in Health Service Management (Griffith University).
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