• Singapore Ministry of Health. Management of diabetic retinopathy. Singapore: Singapore Ministry of Health; 2004 Jan. 32 p. [24 references]

This is the current release of the guideline.

The recommendations that follow summarize the content of the guideline. Please refer to the original guideline document for more detailed recommendations. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the level of evidence (Ia-IV) and the grades of recommendations (A, B, C, and GPP) are defined at the end of the Major Recommendations field.

Detection and Screening for Diabetic Retinopathy

Detection of Diabetic Retinopathy

C - As patients with sight-threatening retinopathy may not have symptoms, life-long evaluation for retinopathy by fundal screening of diabetic patients is a valuable and necessary strategy (American Academy of Ophthalmology Quality of Care Committee, 1993; Kohner & Porta, 1991; American Diabetes Association, 1998; Aiello et al., 1998). (Grade C, Level IV)

Screening for Diabetic Retinopathy

C - It is commended that organization of the screening for diabetic retinopathy be the primary responsibility of the doctor-in-charge of the diabetic patients (Kohner & Porta, 1991). (Grade C Level IV)

GPP - Screening may be performed by fundal photography (preferred method), indirect ophthalmoscopy with slit-lamp biomicroscopy, or direct ophthalmoscopy through dilated pupils. In Singapore, fundal photography has been used for many years. The fundal photography facility should be made widely available to all medical practitioners who wish to send their patients for diabetic retinopathy screening. (GPP)

GPP - Patients with fundi that are poorly visualized due to media opacity should be referred to the ophthalmologist. (GPP)

Screening strategies depend on the rate of appearance and progression of diabetic retinopathy and on the risk factors that alter these rates. The recommended schedule for the initial and follow-up examinations is outlined in the table below.

Table. Eye Examination Schedule

Adapted from American Diabetes Association Clinical Practice Recommendations 2004 (Fong et al., 2004)

Classification of Retinopathy

C - All diabetic patients who are found to have retinopathy by their physicians need to be referred to an ophthalmologist for evaluation (American Academy of Ophthalmology Quality of Care Committee, 1993; Kohner & Porta, 1991; American Diabetes Association, 1998; Aiello et al.,  1998). (Grade C, level IV)

See original guideline document for details about the classification of diabetic retinopathy.

Treatment of Diabetic Retinopathy

Rationale for Treatment

A - Early referral to an ophthalmologist is particularly important for patients with type 2 diabetes and severe non-proliferative (pre-proliferative) retinopathy, since laser treatment at this stage is associated with 50% reduction in the risk of severe visual loss and vitrectomy (American Diabetes Association, 1998; Aiello et al., 1998; Ferris, 1996). (Grade A, Level Ia)

Treatment Strategies for Diabetic Retinopathy

A - The following table shows recommended treatments for various degrees of diabetic retinopathy (Early Treatment Diabetic Retinopathy Study Research Group [ETDRS], 1985; ETDRS "Treatment techniques," 1987; ETDRS "Techniques for scatter," 1987; ETDRS, 1991; ETDRS, 1995).

Table. Treatment Strategies

NPDR - Non-proliferative diabetic retinopathy
PDR - Proliferative diabetic retinopathy
*Especially in older-onset patients (type 2)
+See Section 5.3 on vitreous surgery in the original guideline document

(Grade A, Level Ib)

Vitreous Surgery

GPP - It is advisable to refer cases requiring vitreous surgery to an ophthalmologist familiar with vitreoretinal surgery.

Sight-Threatening Diabetic Retinopathy with Cataract

GPP - In patients in whom the presence of cataract precludes adequate photocoagulation, cataract surgery followed by prompt laser treatment is recommended. However, laser treatment should be given before cataract surgery if fundal visibility permits.

Ophthalmic Follow-up of Diabetic Patients

C - The timing of the follow-up examination of patients with diabetic retinopathy is dependent on the status of the retinopathy.

Table. Ophthalmic Follow-up

Adapted from AAO summary Benchmarks, June 2001
NPDR - Non proliferative diabetic retinopathy
CSME - Clinically significant macular edema
PDR - Proliferative diabetic retinopathy

(Grade C, Level IV)

Definitions:

Levels of Evidence

Level Ia: Evidence obtained from meta-analysis of randomised controlled trials

Level Ib: Evidence obtained from at least one randomised controlled trial

Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation

Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study

Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies

Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Grades of Recommendation

Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation

Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation

Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality

GPP (good practice points): Recommended best practice based on the clinical experience of the guideline development group.

None provided

The type of supporting evidence is identified and graded for most recommendations (see "Major Recommendations").

• Singapore Ministry of Health. Management of diabetic retinopathy. Singapore: Singapore Ministry of Health; 2004 Jan. 32 p. [24 references]

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

2004 Jan

Singapore Ministry of Health - National Government Agency [Non-U.S.]

Singapore Ministry of Health (MOH)

Workgroup on the Management of Diabetic Retinopathy

Workgroup Members: Dr Richard F.T. Fan, Consultant Ophthalmic Surgeon, Mt Elizabeth Medical Centre (Chairman); Dr Ang Chong Lye, Medical Director, Singapore National Eye Centre; Dr Au Eong Kah Guan, Head, Eye Department, Alexandra Hospital; Dr Chee Ka Lin, Caroline, Senior Consultant, Dept of Ophthalmology, National University Hospital; A/Prof Cheong Pak Yean, Cheong Medical Clinic; Dr Chuah Chee Leng, Gerard, Clearvision Eye Clinic; Dr Koh Hock Chuan, Adrian, Consultant, Vitreo-Retina Dept, Singapore National Eye Centre; Dr Ong Sze Guan, Head, Training & Education, Singapore National Eye Centre; Dr Tan Ban Hock, Billy, Ophthalmic Consultants Pte Ltd; Dr Yap Eng Yiat, Clearvision Eye Clinic

Not stated

This is the current release of the guideline.

This NGC summary was completed by ECRI on December 8, 2005.