This is the current release of the guideline.

This guideline updates a previous version: Care of the patient with diabetes mellitus. 3rd ed. St. Louis (MO): American Optometric Association; 2006. 60 p.

Ocular and visual complications of diabetes mellitus:

• Nonproliferative retinopathy
• Proliferative retinopathy
• Macular edema
• Non-retinal ocular and visual complications

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
   • Optical coherence tomography
   • Ocular ultrasound

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 photocoagulation treatment
4. Focal laser treatment
5. Frequent follow-up evaluations (fundus photography, fluorescein angiography)

Effectiveness of management interventions to reduce ocular complications of diabetes

The guideline developer performed literature searches using the following electronic databases:

• Ovid: MedLine, EMBASE, PsycINFO, Global Health
• Web of Science
• Table of contents (electronic): Journal of the American Medical Association, New England Journal of Medicine, Journal of Clinical Epidemiology, British Medical Journal, Health Service Res, Journal of Public Health
• Guidelines International Database

The time period of the literature search was from 1998 (last review period) and forward.

Data and new references were included if the team found groups of published papers to include the same data and/or if the team consensus was to include based on the research results (no ranking criteria were used).

All terms related to the disease of Diabetes and ocular and systemic manifestations of the disease were included in the literature search.

Not stated

Not applicable

Not stated

The American Optometric Association (AOA) Guidelines Review Committee reviews the list of all AOA guidelines per year for currency and solicits experienced and reputable writers to work on guidelines. Together with the writer, references are searched for new information to include or exclude from the current guideline. This team is diversified to include clinical practice doctors, academicians, researchers, and volunteer members from around the country ranging in age, race, ethnicity, gender, and location.

The Committee reviews all resources/references and searches that produce literature for review. After the guideline is updated, the committee re-convenes to review all literature cited in the draft one more time for accuracy.

Not applicable

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

The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and was approved by the AOA Board of Trustees on June 22, 2009.

Diagnosis of Ocular Manifestations of Diabetes Mellitus

Eye examination may be the basis for the first diagnosis of the patient who is unaware of having a diabetic condition. Ocular examination of a patient suspected of having undiagnosed diabetes mellitus (DM) should include all aspects of a comprehensive eye examination (refer to the Optometric Clinical Practice Guideline for Comprehensive Adult Eye and Vision Examination). The examiner should pay particular attention to the ocular and systemic signs and symptoms of DM, as discussed in this section.

Patients diagnosed with DM need regular eye examinations. Examination of the patient with DM 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 of 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
   • Optical coherence tomography (OCT)
   • Ocular ultrasound (US)

Management of Ocular Manifestations of Diabetes Mellitus

Basis for Treatment

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

1. Patients with Undiagnosed Diabetes Mellitus

   The patient suspected of having DM should be screened for high blood glucose. The optometrist should refer the patient to a physician for evaluation or request a fasting blood glucose analysis. The patient with fasting blood glucose values of greater than or equal to 100 mg/dL but less than 126 mg/dL has impaired fasting glucose (IFG) and needs to be retested. Optometrists should refer all patients with fasting blood glucose values of 126 mg/dL or greater 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.

   Optometrists must refer patients with undiagnosed DM who present with DR during the initial examination for treatment of their DM. The DR should be managed in accordance with accepted protocols, as outlined in section II.B.1.c of the original guideline document, which focuses on retinal complications.

2. Patients with Nonretinal Ocular Complications

   Management of nonretinal ocular complications of DM 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. As part of the proper management of DM, the optometrist should make referrals to other appropriately licensed practitioners for concurrent care when indicated.

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

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

Virtually all patients with DM will develop some form of DR at some point during the course of the disease. Therefore, it is important for them to learn about the disease process and the risks for developing ocular signs and symptoms that may result in vision loss. Optometrists should inform patients that retinopathy may exist even when vision is good. Patients should be encouraged to report all ocular symptoms (e.g., blurred vision, flashes, and floaters), inasmuch as DM may be the underlying etiology. Optometrists should help patients understand that timely followup examinations and management are critical for early diagnosis and intervention, when indicated, to reduce the risk of vision loss from DR. Patients also should be informed about their higher risk for other nonretinal ocular complications, such as cataracts, neovascular glaucoma, and open angle glaucoma.

Optometrists should inform their patients about the relationship between the level of control of diabetes and the subsequent development of ocular and other medical complications.

Optometrists should inform patients that diabetic nephropathy, as manifested by microalbuminuria, requires aggressive early treatment.

Prognosis and Follow-up

Diabetic patients who do not have DR should be reexamined annually. The follow-up examination of patients with DR 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

†Other imaging modalities such as optical coherence tomography (OCT) and ocular ultrasonography may be indicated in the presence of diabetic macular edema, vitreous hemorrhage, media opacity, vitreo-retinal traction, and other complications.

*Patient education and written communication with patient's primary care physician are integral to management of DR.
**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.

See the original guideline document for indications on management of patients with severe irreversible vision loss.

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

• Optometric Management of the Patient with Undiagnosed Diabetes Mellitus: A Brief Flowchart
• Optometric Management of the Patient with Diagnosed Diabetes Mellitus: A Brief Flowchart

The type of evidence supporting the recommendations is not specifically stated.

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

An implementation strategy was not provided.

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

American Optometric Association

American Optometric Association Consensus Panel on Diabetes

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)

American Optometric Association (AOA) Clinical Guidelines Coordinating Committee Members: David A. Heath, OD (Chair); John F. Amos, OD, MS; Stephen C. Miller, OD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Care of the patient with diabetes mellitus. 3rd ed. St. Louis (MO): American Optometric Association; 2006. 60 p.

Electronic copies: Available in Portable Document Format (PDF) from the American Optometric Association Web site .

Print copies: Available from the American Optometric Association, 243 N. Lindbergh Blvd., St. Louis, MO 63141-7881.

None available

The following are available:

• Answers to your questions about diabetes & your eyes. Brochure. Available to order from the American Optometric Association (AOA) Web site .
• Diabetic retinopathy. Available in English  and Spanish  from the AOA Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

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. This summary was updated by ECRI Institute on October 11, 2011. The updated information was verified by the guideline developer on November 9, 2011.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions as follows:

Copyright to the original guideline is owned by the American Optometric Association (AOA). NGC users are free to download a single copy for personal use. Reproduction without permission of the AOA is prohibited. Permission requests should be directed to Jeffrey L. Weaver, O.D., Director, Clinical Care Group, American Optometric Association, 243 N. Lindbergh Blvd., St. Louis, MO 63141; (314) 991-4100, ext. 244; fax: (314) 991-4101; e-mail: JLWeaver@AOA.org.