• American Optometric Association. Care of the patient with diabetes mellitus. 3rd ed. St. Louis (MO): American Optometric Association; 2002 Aug 17. 60 p. [104 references]

This is the current release of the guideline.

This guideline updates a previously published version: Care of the patient with diabetes mellitus. 2nd ed. St. Louis (MO): American Optometric Association; 1998. 69 p.

According to the guideline developer, this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.

Ocular and Visual Complications of Diabetes Mellitus

Functional

• Tritan color vision deficiencies
• Refractive error changes
• Accommodative dysfunction
• Visual field defects

Extraocular Muscle Anomalies

Mononeuropathies involving third, fourth, or sixth cranial nerves

Pupillary Reflexes

Sluggish pupillary reflexes

Conjunctiva

Bulbar conjunctival microaneurysms

Tear Film

Tear film deficiencies resulting in dry eye syndrome

Cornea

• Reduced corneal sensitivity
• Reduced corneal wound-healing ability
• Basement membrane abnormalities resulting in increased frequency of abrasions or recurrent erosion syndrome
• Descemet's membrane wrinkling
• Endothelial cell morphology changes, often resulting in increased corneal thickness

Iris

• Depigmentation
• Rubeosis iridis, possibly with associated ectropion uvea and peripheral anterior synechiae
• Neovascular glaucoma

Lens

• Higher prevalence of cataracts
• Reversible opacities and snowflake cataracts (rarely seen in industrialized countries)

Vitreous

Hemorrhage in proliferative retinopathy

Retina

• Nonproliferative retinopathy
• Proliferative retinopathy
• Macular edema

Optic Nerve

• Papillopathy
• Ischemic optic neuropathy
• Open angle glaucoma

Diagnosis
Evaluation
Management
Prevention

Optometry

Health Plans
Optometrists

• To identify patients with undiagnosed diabetes mellitus (DM)
• To identify patients at risk of vision loss from DM
• To preserve human vision by reducing the risk of vision loss in patients with DM through timely diagnosis and intervention
• To improve the quality of care rendered to patients with DM
• To disseminate information and continue the education of health care practitioners regarding the ocular complications of DM and the availability of vision rehabilitation programs
• To stress availability of visual rehabilitation for those with vision loss from DM through low vision devices and psychosocial support

Patients of any age with diabetes mellitus

Diagnosis of Ocular Manifestations of Diabetes Mellitus

1. Patient history
2. Ocular examination
   • Best corrected visual acuity
   • Pupillary reflexes
   • Ocular motility
   • Visual field screening
   • Refraction
   • Biomicroscopy
   • Tonometry
   • Stereoscopic fundus examination with pupillary dilation
3. Supplemental testing
   • Color vision assessment
   • Contrast sensitivity testing
   • Fundus photography or validated retinal imaging
   • Gonioscopy
   • Macular function assessment

Management of Nonretinal Ocular Complications

1. Patient education
2. Specific management strategies, based on type of ocular complication.

Management of Retinal Complications

1. Patient education
2. Referral for consultation and/or treatment
3. Scatter laser treatment
4. Focal laser treatment
5. Frequent follow-up evaluations (fundus photography, fluorescein angiography)

Effectiveness of management interventions to reduce ocular complications of diabetes

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not applicable

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and approved by the AOA Board of Trustees.

Diagnosis of Ocular Manifestations of Diabetes Mellitus

The first diagnosis of the patient who is unaware of having a diabetic condition may be based on an eye examination. Ocular examination of a patient suspected of having undiagnosed diabetes mellitus (DM) should include all aspects of a comprehensive eye examination. Particular attention should be paid to the ocular and systemic signs and symptoms of DM, as discussed in this section.

Patients with DM need regular eye examinations. The examination should include all aspects of a comprehensive eye examination, with supplementary testing as indicated to detect and thoroughly evaluate ocular complications. The frequency of examination is determined on the basis of several factors, including the type of DM, duration of the disease, age of the patient, level of patient compliance, concurrent medical status, and both nonretinal and retinal ocular findings. Due to the risk for progression diabetic retinopathy (DR) during pregnancy, a diabetic woman should have a baseline examination prior to a planned pregnancy or early in the first trimester of pregnancy.

Components of patient care, discussed in greater detail in the guideline document, include the following:

1. Patient history
2. Ocular examination
   • Best corrected visual acuity
   • Pupillary reflexes
   • Ocular motility
   • Visual field screening
   • Refraction
   • Biomicroscopy
   • Tonometry
   • Stereoscopic fundus examination with pupillary dilation
3. Examination technique
4. Supplemental testing
   • Color vision assessment
   • Contrast sensitivity testing
   • Fundus photography or validated retinal imaging
   • Gonioscopy
   • Macular function assessment

Management of Ocular Manifestations of Diabetes Mellitus

Treatment decisions depend upon the extent and severity of the patient's ocular condition.

1. Patients with Undiagnosed Diabetes Mellitus

   Patients suspected of having diabetes mellitus (DM) should be screened for high blood glucose levels. The optometrist should refer the patient to a physician for evaluation or request a fasting blood glucose analysis. Patients with fasting blood glucose values of greater than or equal to 110 mg/dL but less than 126 mg/dL have impaired fasting glucose (IFG) and should be retested. All patients with fasting blood glucose values of 126 mg/dL or greater should be referred to physicians for further evaluation or treatment. Most pregnant women should be screened for glucose intolerance. Because a pregnant patient is usually under medical care, her obstetrician should coordinate this examination.

2. Patients with Nonretinal Ocular Complications

   Management of nonretinal ocular complications of diabetes mellitus should be consistent with current recommendations of care for each condition. The management of nonretinal ocular complications of diabetes mellitus is briefly outlined in the following table. Treatment protocols should always include patient education and recommendations for follow-up visits.

Management of Nonretinal Ocular Complications of Diabetes Mellitus

*Patient education is an integral part of management for all conditions.

3. Patients with Retinal Complications

   When indicated (generally for levels of moderate nonproliferative diabetic retinopathy [NPDR] or worse, any proliferative diabetic retinopathy [PDR], any macular edema, neovascularization of the iris, or unexplained vision loss), the optometrist should refer the DM patients to an ophthalmologist skilled in treating diseases of the retina or a retina specialist.

   Available treatment options, management and follow-up for nonproliferative diabetic retinopathy, proliferative diabetic retinopathy and macular edema are discussed in greater detail in the guideline document.

   Patient education is an important component of care because virtually all patients with diabetes mellitus will develop some form of diabetic retinopathy at some point during the course of the disease.

   Diabetic patients who do not have diabetic retinopathy should be reexamined annually. The follow-up examination of patients with diabetic retinopathy should be scheduled in accordance with the clinical trial protocols. The frequency and composition of evaluation and management visits for retinal complications of diabetes mellitus are summarized in the following table:

Frequency and Composition of Evaluation and Management Visits for Retinal Complications of Diabetes Mellitus

Abbreviations: CSME, clinically significant macular edema; HRC, high risk category; NPDR, nonproliferative diabetic retinopathy; PDR, proliferative diabetic retinopathy; Occ., occasionally

*Patient education and written communication with patient's primary care physician are integral to management of DM.
** Consider scatter laser treatment (PRP), especially if every severe NPDR (see levels of DR), significant medical complication, or type 2 DM
*** Consider scatter laser treatment (PRP), especially if moderate PDR (see levels of DR), significant medical complication, or type 2 DM

Table copyright L.M. Aiello, M.D. Used with permission.

The following clinical algorithms are provided in the original guideline document:

• Optometric Management of the Patient with Undiagnosed Diabetes Mellitus
• Optometric Management of the Patient with Diagnosed Diabetes Mellitus

The type of supporting evidence is not specifically stated for each recommendation.

Until modalities are in place to prevent or cure diabetic retinopathy and other complications of diabetes mellitus, emphasis must be placed on identification, careful follow-up, and timely treatment, including laser photocoagulation, for patients with diabetic retinopathy and diabetic eye disease. Proper care will result in reduction of personal suffering for those involved and a substantial cost savings for the involved individuals, their families, and the country as a whole.

Not stated

• Clinicians should not rely on this Clinical Guideline alone for patient care and management. Please refer to the references and other sources listed in the original guideline for a more detailed analysis and discussion of research and patient care information.
• The components of care described in this guideline are not intended to be all-inclusive; professional judgment and individual patient symptoms and findings may have a significant impact on the nature, extent, and course of the services provided. The optometrist may delegate some components of care.

An implementation strategy was not provided.

Living with Illness

Effectiveness
Patient-centeredness

• American Optometric Association. Care of the patient with diabetes mellitus. 3rd ed. St. Louis (MO): American Optometric Association; 2002 Aug 17. 60 p. [104 references]

Not applicable: The guideline was not adapted from another source.

1993 (revised 2002 Aug 17; reviewed 2007)

American Optometric Association - Professional Association

Funding was provided by the Vision Service Plan (Rancho Cordova, California) and its subsidiary Altair Eyewear (Rancho Cordova, California)

American Optometric Association Consensus Panel on Diabetes

Members: Larry Alexander, OD, Chair; Allen Blume, OD; Jerry Cavallerano, OD, PhD; Brian Den Beste, OD; Jerry Pederson, OD; Lesley L. Walls, OD, MD (1st and 2nd Editions only)

Center for Vision Care Policy Members: Barry Barresi, OD, PhD; Mort Soroka, MPA, PhD; Gary Oliver, OD; Claudia A. Perry, MLS; Leonard Werner, OD

Edited and revised by: Jerry Cavallerano, OD, PhD (1st, 2nd, and 3rd Editions); Ramachandiran Cooppan, MD (1st, 2nd, and 3rd Editions); Sven-Eric Bursell, PhD (1st Edition)

AOA Clinical Guidelines Coordinating Committee Members: John C. Townsend, OD, Chair (3rd Edition); John F. Amos, OD, MS (1st, 2nd, and 3rd Editions); Kerry L. Beebe, OD (1st Edition); Jerry Cavallerano, OD, PhD (1st Edition); John W. Lahr, OD (1st Edition); Thomas L. Lewis, OD, PhD (2nd Edition); W. Howard McAlister, OD, MPH (3rd Edition); Stephen C. Miller, OD (2nd and 3rd Editions); Michael W. Rouse, OD (2nd Edition); Richard L. Wallingford, OD (1st Edition)

Not stated

This is the current release of the guideline.

This guideline updates a previously published version: Care of the patient with diabetes mellitus. 2nd ed. St. Louis (MO): American Optometric Association; 1998. 69 p.

According to the guideline developer, this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.

None available

None available

This summary was completed by ECRI on December 2, 1999. The information was verified by the guideline developer on January 27, 2000. This summary was updated by ECRI on April 16, 2004. The information was verified by the guideline developer on May 10, 2004.