目的：总结浦东新区糖尿病眼病综合防治服务模式的实施成效，为建立完善以社区为基础的糖尿病眼病综合防治服务模式提供实践参考。

方法：于2018-08/2019-08将浦东新区45家社区纳入慢性病管理的糖尿病患者作为筛查对象，根据年龄、性别进行分层抽样，对纳入对象的远程筛查眼健康数据进行分析，并通过问卷调查掌握满意度及参与意愿。

结果：本次筛查纳入DM患者39 055例，均首次建立眼健康档案，远程诊断初步确诊为糖尿病视网膜病变(DR)者15.870%(6198/39055)，其中轻度非增殖性DR、中度非增殖性DR、重度非增殖性DR及增殖性DR者分别为3.974%、9.904%、1.746%、0.246%； 需转诊率44.325%(17311/39055)，实际复诊率5.846%(1012/17311)。此外，DM患者远程筛查满意度与参与意愿均在85%以上。

结论：基于远程诊断系统的糖尿病眼病综合防治服务模式对于实现糖尿病眼病早发现、早诊断、早干预是可行的，但在实际应用中还需进一步优化与完善。

METHODS: From 2018-08 to 2019-08, diabetes patients with chronic disease management were selected for screening in the 45 community of Pudong New Area, stratified sampling by age and sex. The eye health data of long-distance screening were analyzed, and master the degree of satisfaction and participation willingness through the questionnaire survey.

RESULTS: The screening included 39 055 patients with DM, all of whom established eye health files for the first time. 15.870%(6 198/39 055)was made a definite diagnosis preliminarily of diabetic retinopathy, the prevalence of mild, moderate, severe NPDR and PDR were 3.974%, 9.904%, 1.746% and 0.246% respectively. The rate of needing referral was 44.325%(17 311/39 055); the rate of actual follow-up was 5.846%(1 012/17 311); the satisfaction of DR screening and willingness to participate were over 85%.

CONCLUSION: The service mode of comprehensive prevention and treatment for diabetic ophthalmopathy based on remote screening system was feasible for early detection, early diagnosis and early intervention of diabetic ophthalmopathy, but it needs further optimization and improvement in practice application.