Nurse-Led Diabetic Retinopathy Screening: A Revolutionary Approach to Vision Care for Canadian Aboriginal Peoples

Thursday, 27 July 2017: 3:30 PM

Shelley Spurr, PhD, MBA, BSN
Jill Bally, PhD
Carol Bullin, PhD
College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada

Purpose: Aboriginal people living in Canada are among the highest risk populations for diabetes and related complications, including retinopathy (Harris, Bhattacharyya, Dyck, Hayward, & Toth, 2013). Diabetic retinopathy is the most common cause of new cases of blindness in adults ages 20-74. Nearly two thirds (60%) of the population living with type 2 diabetes for 20 years or more suffer from retinopathy, and many individuals (21%) will have symptoms of retinopathy at the time their diabetes was diagnosed (Boyd, Advani, Altomare, & Stockl, 2013). The increasing prevalence of diabetes and the associated complications in Aboriginal peoples illustrate the pressing need to understand the impact of this chronic disease.

To date, visual health has been largely ignored, which has resulted in significant numbers of Aboriginal Canadians suffering from serious ocular and visual health problems. Only a few ocular health programs have evolved targeting Aboriginal communities (Venne, 2011). As such, the purpose of this study was to investigate the risk factors for type 2 diabetes and the possibility of using a portable fundus camera (Optovue) as a novel approach for convenient, earlier, and more accessible vision screening and referral for Aboriginal peoples living with type 2 diabetes in northern and remote Canadian communities. This mobile state-of-the-art technology allows for quick vision screening and can be used by registered nurses to screen for visual changes related to diabetes. The data can be saved and any images of concern can be securely emailed to the off-site ophthalmologist for further investigation.


Study Design: This two stage quantitative pilot study screened participants for identification of risk factors of type 2 diabetes with anthropometrical measurements, blood pressure, and a A1C point of care blood glucose test (Stage 1), followed by vision exams to screen for signs of retinopathy in participants diagnosed with type 2 diabetes using fundus photography (Stage 2).

Population: A purposeful sample of adults living in northern and remote Canadian communities were invited to participate in this pilot study. Participants were recruited from an ophthalmology clinic (n=33) and criteria for the study included a diagnosis of type 2 diabetes.

Stage 1 - Risk Measurements: As recommended by the Canadian Diabetic Association (CDA), weight, height, Body Mass Index (BMI), blood pressure, and an A1C were measured to screen for risk of type 2 diabetes. Descriptive statistics were computed using the Statistical Package for Social Sciences (SPSS v.22.0). Stage 2 - Vision Exams: The first vision exam involved the nurse screening for retinopathy using a portable fundus camera. The second eye exam involved fundus photography completed by the ophthalmologist. The nurse led vision exam results were compared to those of the ophthalmologist to determine sensitivity of the portable fundal camera as a screening tool for detection of diabetic retinopathy. A Cohen's Kappa was used to evaluate the inter-rater agreement between the nurses and ophthalmologist.

Results: Stage 1-BMI: The participant’s BMI measurements ranged 18.75 and 48.63 with a mean of 32.22 (SD = 6.88). The percentage of obesity (>=30) = 54.5%. A1C: The A1C levels ranged from 5.50 to 13.00 with a mean of 8.30 (SD = 1.64). The percentage of elevated BMI (7.1 or higher) = 78.8%. Blood Pressure: The percentage of prehypertension (systolic = 120-130 OR diastolic = 80-89) and hypertension (systolic = 140-159 OR diastolic = 90-99) = 69.6%. Stage 2-Interrater reliability was calculated using Cohen’s Kappa with results demonstrating a moderate agreement between the health professionals’ judgments (k = .67).

Conclusion: Nurse-led vision screening in remote or northern communities can improve the standard of care by extending access to health services, lower the costs to families by reducing travel expenses, and prevent loss of vision for Aboriginal peoples. This research is being used as a foundation to advocate for expanded primary health services to improve the health outcomes for Aboriginal people living with type 2 diabetes in northern and remote Canadian communities. Future research with a larger sample is indicated to validate these results.