Assessment of Diabetic Retinopathy Screening: Problems and Possible Solutions
Dr. Sarah Hayes¹
¹ Endocrinology Outpatient Department, St. John’s Hospital, Limerick, Ireland
Abstract
Background
Diabetic retinopathy (DR) remains one of the leading causes of preventable blindness among adults with diabetes. Since the introduction of the Irish National Diabetic Retinopathy Screening Programme in 2013, screening uptake has improved substantially. However, patient understanding of diabetic retinopathy and satisfaction with the screening process remain insufficiently explored at outpatient clinical level.
Aims
This audit aimed to evaluate patient awareness of diabetic retinopathy screening, identify barriers to engagement, and assess patient satisfaction with the current screening process among individuals attending an endocrinology outpatient clinic.
Methods
A prospective audit was conducted between August and October 2025 at the Endocrinology Outpatient Department of St. John’s Hospital, Limerick. Thirty adult patients aged over 40 years with type 1 or type 2 diabetes completed a five-question anonymised questionnaire assessing understanding of diabetic retinopathy, engagement with educational materials, attendance barriers, adherence to post-screening driving recommendations, and satisfaction with screening result communication.
Results
All participants reported attending diabetic retinopathy screening. Despite excellent attendance, only 10% accurately understood diabetic retinopathy, while 90% demonstrated limited or incorrect knowledge. Eighty-five percent did not read the accompanying information leaflet, commonly citing excessive text and lack of visual explanation. Twenty percent experienced work-related attendance difficulties, and 45% admitted to driving shortly after receiving dilating eye drops despite medical guidance advising against this practice. Twenty-five percent reported dissatisfaction with vague follow-up letters describing “mild retinopathy” without adequate explanation or visual reference.
Conclusions
Although participation in diabetic retinopathy screening was high, patient understanding and satisfaction were poor. Simplified educational materials, clearer communication of results, improved workplace support for attendance, and safer post-screening transport strategies may improve patient engagement and programme effectiveness.
Keywords
Diabetic retinopathy; diabetic retinopathy screening; patient education; health literacy; retinal screening; diabetes care; Ireland; driving safety; outpatient audit
Introduction
Diabetic retinopathy (DR) is among the most common microvascular complications of diabetes mellitus and remains a leading cause of preventable blindness among working-age adults worldwide. Early detection and timely treatment are essential for reducing visual impairment and preventing progression to severe retinal disease.
Population-based diabetic retinopathy screening programmes have significantly improved outcomes in several countries. The United Kingdom established a national DR screening programme between 2002 and 2007, contributing to measurable reductions in diabetes-related blindness. Following this model, the Irish National Diabetic Retinopathy Screening Programme was introduced by the Health Service Executive (HSE) in 2013, providing free annual or biennial retinal imaging for eligible individuals with diabetes.
Despite strong national screening uptake, relatively little research has focused on patient understanding of diabetic retinopathy, satisfaction with communication, or adherence to post-screening guidance. Effective screening programmes depend not only on attendance but also on patient comprehension, engagement, and confidence in the process.
This prospective audit examined patient awareness, attitudes, and perceived barriers relating to diabetic retinopathy screening within an endocrinology outpatient setting, twelve years after implementation of the national screening programme.
Methods
Study Setting and Participants
A prospective audit was conducted between August and October 2025 within the Endocrinology Outpatient Department of St. John’s Hospital, Limerick, Ireland.
Thirty consecutive adult patients aged over 40 years with either type 1 or type 2 diabetes attending routine endocrine outpatient follow-up appointments were invited to participate. Patient consent was obtained from all participants. Ethical approval was not required as the project was conducted as a clinical audit in accordance with institutional audit policies and the principles of the Declaration of Helsinki.
Audit Design
Participants who reported attending diabetic retinopathy screening were invited to complete a brief five-question anonymised questionnaire exploring:
- Understanding of diabetic retinopathy
- Engagement with screening information leaflets
- Willingness and ability to attend appointments despite work commitments
- Driving behaviour following administration of dilating eye drops
- Satisfaction with screening result communication
Verbal clarification of questions was permitted when necessary. Quantitative data were summarised descriptively using percentages, while qualitative responses were analysed for recurring themes.
Results
Screening Uptake
All thirty participants reported attending the national diabetic retinopathy screening programme, representing a 100% attendance rate within this outpatient cohort. This exceeded the 72% uptake reported in the 2023 national Diabetic RetinaScreen Market Research survey and compared favourably with international screening uptake data.
Understanding of Diabetic Retinopathy
Only 10% of participants accurately described diabetic retinopathy as a diabetes-related condition affecting retinal blood vessels. The remaining 90% demonstrated incomplete or incorrect understanding, frequently describing DR using vague terminology such as “spots in the eye” or “floaters.”
These findings suggest that attendance alone does not guarantee meaningful patient understanding of retinal disease or screening objectives.
Engagement with Educational Materials
Most participants reported limited engagement with educational information provided before screening appointments. Eighty-five percent admitted they had not read the accompanying information leaflet.
Commonly cited reasons included:
- Excessive written content
- Use of medical terminology
- Lack of visual explanations
- Limited time or interest before appointments
Several participants indicated that simplified visual materials or shorter educational formats would improve engagement and comprehension.
Work-Related Attendance Barriers
Twenty percent of participants reported difficulties attending appointments due to employment-related constraints, particularly among self-employed individuals or those without paid medical leave. Some participants described financial stress associated with taking time away from work.
Twenty-five percent reported previously rescheduling screening appointments because of occupational or logistical challenges.
Driving After Pharmacologic Dilation
Forty-five percent of participants admitted to driving within 10–20 minutes after receiving dilating eye drops, despite medical guidance advising against driving for several hours following pupil dilation.
Reasons included:
- Lack of alternative transport
- Perceived improvement in vision shortly after screening
- Reluctance to depend on family or friends for transport
Several patients were unaware that impaired vision following dilation may compromise driving safety and potentially invalidate motor insurance coverage in the event of a road traffic accident.
Satisfaction with Screening Communication
Twenty-five percent of participants expressed dissatisfaction with follow-up result letters, particularly regarding terminology such as “mild retinopathy.”
Patients frequently described the communication as:
- Vague
- Difficult to interpret
- Anxiety provoking
- Insufficiently explanatory
Many participants suggested that including retinal images or simple visual diagrams illustrating disease stage could improve understanding and reassurance.
Discussion
This audit identified important communication and health literacy challenges within the Irish National Diabetic Retinopathy Screening Programme despite excellent screening attendance rates.
The most striking finding was the substantial gap between attendance and understanding. Although all participants attended screening, only a minority could accurately explain diabetic retinopathy or understand the purpose of retinal screening. This discrepancy suggests that existing educational strategies may not adequately engage patients in real-world clinical practice.
The poor uptake of educational leaflets reflects broader issues relating to health literacy and accessibility of medical information. Previous studies have demonstrated that visually guided educational materials improve patient comprehension and information retention, particularly among individuals managing chronic disease.
Workplace and transportation barriers also influenced screening participation and adherence to guidance. Difficulties obtaining leave from work or arranging transport following pupil dilation created additional stress surrounding attendance. These findings highlight the importance of considering socioeconomic and practical barriers when designing preventive healthcare programmes.
The high proportion of patients driving shortly after dilation raises significant safety and medicolegal concerns. Current guidance advising patients that they “should not drive” may not sufficiently communicate the seriousness of impaired vision following pharmacologic dilation. Clearer public health messaging and improved transport support strategies may be warranted.
Finally, dissatisfaction with follow-up communication demonstrates the importance of patient-centred result reporting. Simplified explanations and visual representation of retinal findings may improve patient understanding, reduce anxiety, and encourage adherence to future follow-up care.
Recommendations
Several practical measures may improve patient engagement and effectiveness of diabetic retinopathy screening programmes:
- Simplification of educational materials using concise language and visual illustrations
- Introduction of standardised result letters incorporating labelled retinal images and disease staging
- Improved workplace support and consideration of paid medical leave for chronic disease screening attendance
- Development of transport assistance options following pharmacologic dilation
- Evaluation of non-mydriatic retinal imaging technologies to reduce dependence on dilating eye drops
Conclusion
Twelve years after the implementation of Ireland’s National Diabetic Retinopathy Screening Programme, this audit demonstrates that high attendance does not necessarily equate to effective patient understanding or satisfaction.
Significant gaps remain in health literacy, communication, and adherence to post-screening safety guidance. Addressing these issues through simplified education, clearer communication strategies, and practical support measures may improve patient engagement and strengthen the long-term effectiveness of diabetic retinopathy screening in preventing avoidable blindness.
Open Access & Copyright
© 2026 The Authors. Published by the European Medical Specialist Review (EMSR) under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0).