Non-mydriatic Polaroid photography in screening for diabetic retinopathy SIR,-I have been using a non-mydriatic camera in a district general hospital diabetic clinic for the past three years and think that the finding by Dr D Jones and colleagues (9 April, p 1029) that one in five Polaroid photographs are uninterpretable is a remarkably high figure; in our experience failures are fewer than 1 in 10.The age distribution of patients in their study is not mentioned; problems caused by constricted pupils and lens opacities rise progressively over the age of 65. If both eyes are photographed at the same clinic visit we have found that the second photograph is invariably of poorer quality than the first, and our practice now is to photograph the contralateral eye at the next clinic visit.We have been screening all patients under 65 attending the diabetic clinic. Those with visual symptoms and those known to have retinopathy who were already under review by an ophthalmologist were excluded. The patients' mean age was 42-8 years (range 16-65) and mean duration of diabetes 9-8 years (range 0-47); 63% had type 1 diabetes. A total of 1166 retinas were examined with a Canon CR2-NM camera and Polaroid 779 film. Retinopathy (maculopathy, cotton wool spots, new vessels, and intraretinal microvascular abnormalities) was identified in 54 retinas (4 6%).In an ideal world diabetic patients would undergo annual fluorescein angiography or be examined through dilated pupils by a consultant ophthalmologist (although many of my patients would be unwilling to submit repeatedly to either of these experiences). This utopian situation is unlikely to occur in most district general hospital diabetic clinics and the non-mydriatic camera should not be dismissed without further evaluation. In the late 1960s and 1970s comprehensive reviews of the value of screening for a variety of conditions and the criteria to be observed before introducing screening were published.`3 Furthermore, the Department of Health funded a major controlled trial of the value of multiphasic screening in middle age.4 In suggesting that health checks might be of value the authors of the white paper do not appear to have taken into account the results of these studies (funded by the Department of Health and Social Security).In view of the correct insistence by the present government on the improvement of efficiency and effectiveness in the National Health Service, it is disappointing to find its own white paper wanting to perpetuate ineffective and inefficient procedures.W W HOLLAND

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