Diabetic eye screening when a patient declines dilation
Mrs T, 58, is a Māori woman with type 2 diabetes for 12 years and an HbA1c of 9.4%. Her last retinal screening was 3 years ago. She attends with blurred vision and occasional floaters, and says she feels well. She has brought her 4-year-old mokopuna because there is no other childcare. She has a 1-hour bus trip home and declines dilating drops because she is worried about driving and about being late for her granddaughter. Undilated examination shows hazy media from cataract and no clear view of the retina. Acuity is 6/9 right and 6/12 left, with no improvement on pinhole. She says, 'I just need new glasses.' The clinic has tropicamide, phenylephrine, a direct ophthalmoscope and a telephone, but no ultra-widefield camera today.
1. Why is dilation necessary, and how would you discuss it with Mrs T in a culturally safe way?
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Dilation is necessary because diabetic retinopathy can be asymptomatic until it is sight-threatening. Undilated views through cataract are inadequate to exclude macular oedema, proliferative retinopathy or vitreous haemorrhage. Her blurred vision, floaters and long interval since screening raise concern.
A culturally safe conversation would start with her priorities, not the test. I would:
- ask what she has noticed and what worries her most, including getting home for her mokopuna;
- explain plainly that the drops widen the pupil so I can see the back of the eye, and that cataract is making the view cloudy;
- explain the effects: blurry near vision, sensitivity to light and difficulty driving for several hours;
- explore practical solutions: can a whānau member collect her, can the visit be timed for when she has support, can the mokopuna be cared for during the appointment, or can transport be arranged;
- avoid blame about her diabetes or the gap in screening;
- offer an interpreter or use plain language if needed, and check understanding by asking her to tell me the plan in her own words;
- respect her decision and document it.
I would also acknowledge that she came a long way and that her time and caregiving responsibilities matter.
2. What are the possible causes of her reduced vision and what immediate actions are required if she continues to decline dilation?
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Possible causes include cataract, diabetic macular oedema, non-proliferative or proliferative diabetic retinopathy, vitreous haemorrhage (which may explain floaters), refractive change and, less likely, other macular or optic nerve disease. The poor pinhole improvement makes simple refractive error less likely.
If she continues to decline:
- document informed refusal, including that the retina could not be assessed and the risks were explained;
- do not simply prescribe glasses and discharge her;
- offer another appointment with dilation and support, and ask whether she would accept referral to a retinal screening service or ophthalmology;
- arrange urgent ophthalmology review if there are red flags: sudden visual loss, a sudden increase in floaters or flashes, pain, rubeosis, or a visible vitreous haemorrhage;
- with her consent, communicate with her GP and diabetes team about the missed screening and the need for retinal assessment;
- ensure the message is not 'you failed' but 'your eyes need a proper look and we can help you get there'.
Because her vision is already reduced, I would lean towards ophthalmology referral rather than waiting for a routine screening cycle.
3. How would you address equity and coordination with her diabetes team?
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Equity means recognising that a 1-hour bus trip, childcare responsibilities, cost and past experiences of health care can make attendance harder. It does not mean lowering the standard of care; it means removing barriers to achieving it.
I would:
- offer flexible appointment times and, where possible, coordinate with a local Māori health provider or community screening service;
- ask whether she wants whānau support at the appointment and record that preference;
- provide written information in plain language and check understanding;
- send a concise report to her GP and diabetes team, with consent, noting the failed undilated view, the need for retinal assessment and any red flags;
- flag the HbA1c of 9.4% as relevant to retinopathy risk without making her feel judged;
- ensure the recall is active rather than passive: a phone call, not just a letter, and a named contact;
- document the barriers and the plan so the next clinician does not start from scratch.
The aim is a coordinated pathway that respects her autonomy and her role as a caregiver while ensuring her sight-threatening risk is not lost in the system.