A integração enfermagem-oftalmologia na atenção primária à saúde, por meio da teleoftalmologia, permite o rastreamento adequado da retinopatia diabética e reduz a sobrecarga de atendimento na atenção secundária

Abstract

Diabetes mellitus (DM) is a complex metabolic disease with a relative or absolute insulin deficiency affecting the Metabolism of carbohydrates, lipids, and proteins. DM is associated with chronic cardiovascular disease, peripheral and autonomic nervous system alterations, and microvascular complications. Retinopathy is one of the most common complications, especially in patients with long-term disease and poor glycemic control. Early identification of diabetic retinopathy (DR), combined with the proper treatment of DM and hypertension, may slow its progression, and protect against vision loss. Annual screening for DR is a cost-effective method of reducing preventable blindness. However, the availability of ophthalmologists in the Unified Health Service (SUS) has been deficient and unable to deal with the increasing DM prevalence. The improvement of digital technologies and the greater consolidation of telehealth are creating opportunities for more effective screening, diagnosis, and management of DR. In this sense, the objectives of this research were to analyze: 1) the feasibility to use digital technology, associated with telemedicine, and the quality of the images captured by nursing professionals; 2) the prevalence of DR, using digital health technology associated with telemedicine, in type 2 DM individuals followed up at a primary health care unit (PHC); and 3) whether DR diagnosis, by portable fundus camera, may shorten the waiting time for a specialist consultation in the SUS. This is a prospective study with a sample of 783 participants, selected and evaluated from February to June 2020. In the first phase, nurses from PHC were trained to use a portable fundus camera. The images captured were assessed for quality. The image acquisition learning curve was evaluated according to the number of exams which allowed a clinical decision, that is, gradable images. After that, all eligible individuals were examined, and those with retinal alterations, ocular media opacities or non-gradable images were referred to the ophthalmologist. After the 7th day, the gradable image rate was maintained above 80%. A total of 779 participants were evaluated, 120 exams did not allow a clinical decision and other 72 had opacity of ocular means, 436 individuals were identified as DR-absent and 151 as DR-present. The retina evaluation, by teleophthalmology, was possible in 75.3% of the 779 participants, and the prevalence of DR reached 25.7%. The participants classified as DR-present had significantly higher mean HbA1c and duration of diabetes than those DR-absent (p=0.009 and p<0.001, respectively). The waiting time for an ophthalmologist consultation ranged from 23 to 240 days, and the mean and standard deviation was 17 162.8 ± 54 days. Our results allowed the following conclusions: 1) the use of portable fundus camera by the nursing team proved to be a viable strategy for tracking DR in primary health care; 2) the prevalence of DR diagnosed by teleophthalmology was 25.7% in individuals with type 2 DM; and 3) we did not identify a reduction in the waiting time for a specialist consultation, which ranged from 23 to 240 days. However, the nursing-ophthalmology integration, via teleophthalmology, contributed to better management and use of resources, since most participants were classified as DR-absent and with indication to keep the follow-up in primary care.