The management of diabetic retinopathy in the public sector of eThekwini district of KwaZulu-Natal

Abstract

Background: Estimates from the year 1990–2010 showed an increase in blindness and vision impairment (moderate or severe) because of diabetic retinopathy (DR) in Sub-Saharan Africa’s sub-regions (central, eastern, southern and western Africa).¹ The rate of DR in South Africa is expected to increase because of the lack of screening protocols and policies for the management of diabetic eye disease in the district health system of South Africa.

Aim: The purpose of this study was to determine the current role of healthcare practitioners (HCPs) towards managing DR in the eThekwini district of KwaZulu-Natal.

Method: A cross-sectional study was conducted, and questionnaires were distributed to a total of 104 HCPs in public health institutions situated in the northern eThekwini district of KwaZulu-Natal. Clinics and community health centres (CHCs) were selected based on the assumption that primary healthcare nurses, medical officers (MOs) and ophthalmic nurses and/or optometrists practice at these institutions. The hospitals selected were the referral institutions for the selected clinics and CHCs. The questionnaires distributed included questions relating to diabetic patient registers, referrals to and from other HCPs, management of ocular complications, ocular screening methods, fundus examinations and involvement in screening programmes.

Results: Over a third of the ophthalmologists (35.3%) indicated that DR was present at the initial examination in more than 50% of patients, though overall ophthalmologists reported loss of vision in at least one eye in fewer than 5% of patients on presentation. Less than half of the public sector general practitioners or MOs (40.6%) conducted fundus examinations but 90.6% did not dilate pupils, although 71.9% had knowledge on the use of a direct ophthalmoscope. Only 40.6% of the MOs discussed the ocular complications of uncontrolled diabetes mellitus (DM) with patients and 62.5% encouraged regular eye examinations. Less than 50% of the MOs (43.8%) referred patients complaining of visual difficulties to optometrists and 9.4% referred to the ophthalmic nurses. Only 6.25% referred patients with DM needing further evaluation to ophthalmologists. Data from the optometrists were inconclusive because of the poor response rate of 5 (20%). None of the ophthalmic nurses reported doing fundus photography or refractions. Two-thirds of the ophthalmic nurses were interested in training to properly grade DR.

Conclusion: The study established that there are key challenges in referral, training and practice in the management of DR. These need to be addressed in order to develop a comprehensive approach for the prevention and management of visual impairment and blindness because of DM.