The ratings of importance to the care process, (A-C) and the ratings for strength of evidence, (I-III) are defined at the end of the "Major Recommendations" field.
Diagnosis
History
- Duration of diabetes (Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years," 1984; Klein et al., 1988; Davis et al., 1998) [A:I]
- Past glycemic control (hemoglobin A1c) (Klein et al., 1988; Davis et al., 1998; The Diabetes Control and Complications Trial Research Group, 1995) [A:I]
- Medications [A:III]
- Medical history (e.g., obesity, [A:III] renal disease, (Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years," 1984; Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years," 1984) [A:II] systemic hypertension, (Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years," 1984; Klein et al.," Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years," 1984) [A:I] serum lipid levels, (Chew et al., 1996) [A:II] pregnancy (Klein, Moss, & Klein, 1990; Chew et al., 1995) [A:I])
- Ocular history [A:III] (e.g., trauma, ocular injection, surgery, including laser treatment and refractive surgery)
Examination
- Visual acuity (Early Treatment Diabetic Retinopathy Study Research Group, ETDRS report number 9, 1991) [A:I]
- Slit-lamp biomicroscopy [A:III]
- Intraocular pressure [A:III]
- Gonioscopy when indicated [A:III]
- Dilated funduscopy including stereoscopic examination of the posterior pole (Early Treatment Diabetic Retinopathy Study Research Group, 1985) [A:I]
- Examination of the peripheral retina and vitreous [A:III]
A dilated pupil is necessary to ensure optimal examination of the retina, because only 50% of eyes are correctly classified for the presence and severity of retinopathy through undilated pupils (Klein et al., 1985). [A:I] Slit-lamp biomicroscopy with accessory lenses is the recommended method to evaluate retinopathy in the posterior pole and midperipheral retina (Early Treatment Diabetic Retinopathy Study Research Group, 1985). [A:III] The examination of the peripheral retina is best performed with indirect ophthalmoscopy or with slit-lamp biomicroscopy, combined with a contact lens. [A:III]
Examination Schedule
Recommended Eye Examination Schedule for Patients with Diabetes Mellitus
| Diabetes Type |
Recommended Time of First Examination |
Recommended Follow-up* |
| Type 1 |
3-5 years after diagnosis (Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years," 1984) [A:II] |
Yearly (Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years," 1984 [A:II] |
| Type 2 |
At time of diagnosis (Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years," 1984; "The prevalence of retinopathy in impaired glucose tolerance," 2007) [A:II] |
Yearly (Klein et al., "Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years," 1984; "The prevalence of retinopathy in impaired glucose tolerance," 2007) [A:II] |
| Prior to pregnancy (type 1 or type 2) |
Prior to conception or early in the first trimester (Klein, Moss, & Klein, 1990; Chew et al., 1995; The Diabetes Control and Complications Trial Research Group, 2000) [A:I] |
No retinopathy to mild or moderate nonproliferative diabetic retinopathy (NPDR): every 3-12 months [A:I]
Severe NPDR or worse: every 1-3 months [A:I]
(Klein, Moss, & Klein., 1990; Chew et al., 1995; The Diabetes Control and Complications Trial Research Group, 2000)
|
*Abnormal findings may dictate more frequent follow-up examinations.
Treatment
Laser photocoagulation surgery is the standard technique for treating diabetic retinopathy. In general, it is advised for patients with high-risk proliferative diabetic retinopathy, clinically significant macular edema, or neovascularization of the anterior chamber angle (Murphy & Egbert, 1979; The Diabetic Retinopathy Study Research Group, 1987; Early Treatment Diabetic Retinopathy Study Research Group, 1987). [A:I] Detailed management recommendations for patients with diabetes are summarized in the table below and are described in the main text of the original guideline document.
Table: Management Recommendations for Patients with Diabetes
| Severity of Retinopathy |
Presence of Clinically Significant Macular Edema (CSME1) |
Follow-up (Months) |
Panretinal Photocoagulation (Scatter) Laser |
Fluorescein Angiography |
Focal and/or Grid Laser2 |
| 1. Normal or minimal non-proliferative diabetic retinopathy (NPDR) |
No |
12 |
No |
No |
No |
| 2. Mild to moderate NPDR |
No
Yes
|
6-12
2-4
|
No
No
|
No
Usually
|
No
Usually1, 3
|
| 3. Severe NPDR |
No
Yes
|
2-4
2-4
|
Sometimes4
Sometimes4
|
Rarely
Usually
|
No
Usually5
|
| 4. Non-high-risk proliferative diabetic retinopathy (PDR) |
No
Yes
|
2-4
2-4
|
Sometimes4
Sometimes4
|
Rarely
Usually
|
No
Usually3
|
| 5. High-risk PDR |
No
Yes
|
2-4
2-4
|
Usually
Usually
|
Rarely
Usually
|
No
Usually5
|
| 6. Inactive/ involuted PDR |
No
Yes
|
6-12
2-4
|
No
No
|
No
Usually
|
Usually
Usually
|
1Exceptions include: hypertension or fluid retention associated with heart failure, renal failure, pregnancy, or any other causes that may aggravate macular edema. Deferral of photocoagulation for a brief period of medical treatment may be considered in these cases. Also, deferral of CSME treatment is an option when the center of the macula is not involved, visual acuity is excellent, close follow-up is possible, and the patient understands the risks.
2Adjunctive treatments that may be considered include intravitreal corticosteroids or anti-vascular endothelial growth factor agents (off-label use).
3Deferring focal photocoagulation for CSME is an option when the center of the macula is not involved, visual acuity is excellent, close follow-up is possible, and the patient understands the risks. However, initiation of treatment with focal photocoagulation should also be considered because, although treatment with focal photocoagulation is less likely to improve the vision, it is more likely to stabilize the current visual acuity. Treatment of lesions close to the foveal avascular zone may result in damage to central vision and with time, such laser scars may expand and cause further vision deterioration. Closer follow-up may be necessary for macular edema that is not clinically significant.
4Panretinal photocoagulation surgery may be considered as patients approach high-risk PDR. The benefit of early panretinal photocoagulation at the severe nonproliferative or worse stage of retinopathy is greater in patients with type 2 diabetes than in those with type 1. Treatment should be considered for patients with severe NPDR and type 2 diabetes. Other factors, such as poor compliance with follow-up, impending cataract extraction or pregnancy, and status of the fellow eye will help in determining the timing of the panretinal photocoagulation.
5It is preferable to perform focal photocoagulation first, prior to panretinal photocoagulation, to minimize panretinal photocoagulation laser-induced exacerbation of the macular edema.
Follow-Up
History
- Symptoms [A:III]
- Systemic status (pregnancy, blood pressure, serum cholesterol, renal status) [A:III]
- Glycemic status (hemoglobin A1c) (Klein et al., 1988; Davis et al., 1998; The Diabetes Control and Complications Trial Research Group, 1995) [A:I]
Examination
A follow-up examination should include the following elements:
- Visual acuity (Early Treatment Diabetic Retinopathy Study Research Group, ETDRS report number 9, 1991) [A:I]
- Slit-lamp biomicroscopy with iris examination (Jacobson, Murphy, & Rosenthal, 1979) [A:II]
- Intraocular pressure [A:III]
- Gonioscopy (if iris neovascularization is suspected or present or if intraocular pressure is increased) (Jacobson, Murphy, & Rosenthal, 1979) [A:II]
- Stereoscopic examination of the posterior pole after dilation of the pupils (Early Treatment Diabetic Retinopathy Study Research Group, 1985) [A:I]
- Peripheral retina and vitreous examination, when indicated (Early Treatment Diabetic Retinopathy Study Research Group, ETDRS report number 12, 1991) [A:II]
Recommended intervals for follow-up are given in the above table.
Provider
Because of the complexities of the diagnosis and surgery for proliferative diabetic retinopathy, the ophthalmologist caring for patients with this condition should be familiar with the specific recommendations of the Diabetic Retinopathy Study, Early Treatment Diabetic Retinopathy Study, the United Kingdom Prospective Diabetes Study, Diabetes Control and Complications Trial, and the Epidemiology of Diabetes Interventions and Complications. [A:III] The ophthalmologist should also have training in and experience with the management of this particular condition. [A:III]
Counseling/Referral
The ophthalmologist should refer patients with diabetes who do not have a primary care physician for appropriate management of their systemic condition. [A:III] The ophthalmologist should communicate examination results to the physician who is managing ongoing diabetes care. [A:III]
Those whose conditions fail to respond to surgery and those for whom further treatment is unavailable should be provided with proper professional support and offered referral for counseling, vision rehabilitation, or social services as appropriate (American Academy of Ophthalmology Vision Rehabilitation Committee, 2007). [A:III] Vision rehabilitation restores functional ability (Stelmack et al., 2008) [A:I] and patients with functionally limiting postoperative visual impairment should be referred for vision rehabilitation and social services (American Academy of Ophthalmology Vision Rehabilitation Committee, 2007). [A:III] More information on vision rehabilitation, including materials for patients, is available at http://www.aao.org/smartsight.
Definitions:
Ratings of Importance to Care Process
Level A, defined as most important
Level B, defined as moderately important
Level C, defined as relevant but not critical
Ratings of Strength of Evidence
Level I includes evidence obtained from at least one properly conducted, well-designed randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
Level II includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies, preferably from more than one center
- Multiple-time series with or without the intervention
Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization (e.g., Preferred Practice Patterns [PPP] panel consensus with external peer review)
