• American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Diabetic retinopathy. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 33 p. [98 references]

The ratings of importance to the care process, (A, B, C) and the ratings for strength of evidence, (I, II, III) are defined at the end of the "Major Recommendations" field.

Diagnosis

The initial examination for a patient with diabetes mellitus includes all features of the comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to diabetic retinopathy.

History

An initial history should consider the following elements:

• Duration of diabetes [A:I]
• Past glycemic control (hemoglobin A_1c) [A:I]
• Medications [A:III]
• Medical history (e.g., onset of puberty, [A:III] obesity, [A:III] renal disease, [A:II] systemic hypertension, [A:I] serum lipid levels, [A:II] pregnancy [A:I])

Examination

The initial examination should include the following elements:

• Best-corrected visual acuity [A:I]
• Intraocular pressure [A:III]
• Gonioscopy when indicated [A:III]
• Slit-lamp biomicroscopy [A:III]
• Dilated funduscopy including stereoscopic examination of the posterior pole [A:I]
• Examination of the peripheral retina and vitreous [A:III]

Slit-lamp biomicroscopy with accessory lenses is the recommended method to evaluate retinopathy in the posterior pole and midperipheral retina. [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	5 years after onset [A:II]	Yearly [A:II]
Type 2	At time of diagnosis [A:II]	Yearly [A:II]
Prior to pregnancy (type 1 or type 2)	Prior to conception or early in the first trimester [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]

*Abnormal findings may dictate more frequent follow-up examinations.

Treatment

Management recommendations for patients with diabetic retinopathy are summarized in the table below.

Management Recommendations for Patients with Diabetes
 

Severity of Retinopathy	Presence of clinically significant macular edema (CSME1)	Follow-up (Months)	Scatter (Panretinal) Laser	Fluorescein Angiography	Focal Laser2
1. Normal or minimal 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 or very severe NPDR	No  Yes	2-4  2-4	Sometimes4 Sometimes4	Rarely  Usually	No  Usually5
4. Non-high-risk PDR	No  Yes	2-4  2-4	Sometimes4 Sometimes4	Rarely  Usually	No  Usually3
5. High-risk PDR	No  Yes	3-4  3-4	Usually  Usually	Rarely  Usually	No  Usually5
6. High-risk PDR not amenable to photocoagulation (e.g., media opacities)	--	1-6	Not Possible6	Occasionally	Not Possible6

1. Exceptions 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.
2. Focal photocoagulation refers to direct focal laser to leaking microaneurysms or a grid photocoagulation pattern to areas of diffuse leakage or nonperfusion seen on fluorescein angiography.
3. Deferring 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.
4. Scatter (panretinal) photocoagulation surgery may be considered as patients approach high-risk PDR. The benefit of early scatter 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 scatter photocoagulation.
5. Some experts feel that it is preferable to perform focal photocoagulation first, prior to scatter photocoagulation, to minimize scatter laser-induced exacerbation of the macular edema.
6. Vitrectomy is indicated in selected cases.

Follow-up

The follow-up evaluation includes a history and examination.

History

A follow-up history should include changes in the following:

• Symptoms [A:III]
• Systemic status (pregnancy, blood pressure, renal status) [A:III]
• Glycemic status (hemoglobin A_1c) [A:I]

Examination

A follow-up examination should include the following elements:

• Visual acuity [A:I]
• Intraocular pressure [A:III]
• Slit-lamp biomicroscopy with iris examination [A:II]
• Gonioscopy (if iris neovascularization is suspected or present or if intraocular pressure is increased) [A:II]
• Stereo examination of the posterior pole with dilation of the pupils [A:I]
• Peripheral retina and vitreous examination, when indicated [A:II]

Recommended intervals for follow-up are given in the above table.

Provider

Because of the complexities of the diagnosis and surgery for PDR, the ophthalmologist caring for patients with this condition should be familiar with the specific recommendations of the Diabetic Retinopathy Study (DRS), Early Treatment Diabetic Retinopathy Study (ETDRS), United Kingdom Prospective Diabetes Study (UKPDS), and Diabetes Control and Complications Trial (DCCT). [A:III] The ophthalmologist should also have training in and experience with the management of this particular condition. [A:III]

Counseling/Referral

Patient education about the importance of maintaining near-normal glucose levels and near-normal blood pressure and lowering serum lipid levels is an important aspect of the care process. [A:III]

Patients with diabetes mellitus without diabetic retinopathy should be encouraged to have annual dilated eye examinations to detect the onset of diabetic retinopathy. [A:III] Patients should also be informed that effective treatment for diabetic retinopathy depends on timely intervention, despite good vision and no ocular symptoms. [A:III]

Those patients 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. [A:III]

Definitions:

Ratings of Importance to Care Process

Level A, most important
Level B, moderately important
Level C, relevant but not critical

Ratings of Strength of Evidence

1. 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.
2. 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
3. Level III includes evidence obtained from one of the following:
• Descriptive studies
• Case reports
• Reports of expert committees/organization
• Expert opinion (e.g., Preferred Practice Pattern panel consensus)

• American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Diabetic retinopathy. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 33 p. [98 references]

Retina Panel Members: Emily Y. Chew, MD (Chair); William E. Benson, MD; H. Culver Boldt, MD; Tom S. Chang, MD; Louis A. Lobes, Jr., MD; Joan W. Miller, MD; Timothy G. Murray, MD; Marco A. Zarbin, MD, PhD; Leslie Hyman, PhD (Methodologist)

Preferred Practice Patterns Committee Members: Joseph Caprioli, MD (Chair); J. Bronwyn Bateman, MD; Emily Y. Chew, MD; Douglas E. Gaasterland, MD; Sid Mandelbaum, MD; Samuel Masket, MD; Alice Y. Matoba, MD; Donald S. Fong, MD, MPH

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Ophthalmology (AAO), Preferred Practice Patterns Committee, Retina Panel. Diabetic retinopathy. San Francisco (CA): American Academy of Ophthalmology (AAO); 1998. 32 p.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant.

Electronic copies: Available from the American Academy of Ophthalmology (AAO) Web site.

Print copies: Available from American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120-7424; telephone, (415) 561-8540.

The following patient education booklet is available:

• Diabetic retinopathy (2001)

The following patient education brochure is available:

• Diabetic retinopathy (1998)
• Diabetic Retinopathy (Spanish: Retinopatia Diabetica) (1998).

The following patient education videotape is available:

• Diabetic retinopathy (1990)

Print copies: Available from the American Academy of Ophthalmology (AAO), P.O. Box 7424, San Francisco, CA 94120-7424; Phone: (415) 561-8540.

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.