Retinopathy

Canadian Diabetes Association Clinical Practice Guideline Expert Committee

Shelley R. Boyd MD, FRCSC Andrew Advani MB ChB, PhD, FRCP(UK) Filiberto Altomare MD, FRCSC Frank Stockl MD, FRCSC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Screening is important for early detection of treatable disease. Screening intervals for diabetic retinopathy vary according to the individual's age and type of diabetes.
  • Tight glycemic control reduces the onset and progression of sight-threatening diabetic retinopathy.
  • Laser therapy, local intraocular pharmacological therapy and surgery reduce the risk of significant visual loss.

Highlights of Revisions

  • A new recommendation addresses the use of fenofibrate for retinopathy.
Table 1
Screening for retinopathy
BP, blood pressure.
See “Other Relevant Guidelines”.
When to initiate screening
  • Five years after diagnosis of type 1 diabetes in all individuals ≥15 years
  • In all individuals at diagnosis of type 2 diabetes
Screening methods
  • Seven-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader (gold standard)
  • Direct ophthalmoscopy or indirect slit-lamp funduscopy through dilated pupil
  • Digital fundus photography
If retinopathy is present
  • Diagnose retinopathy severity and establish appropriate monitoring intervals (≤1 year)
  • Treat sight-threatening retinopathy with laser, pharmacological or surgical therapy
  • Review glycemic, BP and lipid control, and adjust therapy to reach targets per guidelines
  • Screen for other diabetes complications
If retinopathy is not present
  • Type 1 diabetes: rescreen annually
  • Type 2 diabetes: rescreen every 1–2 years
  • Review glycemic, BP and lipid control, and adjust therapy to reach targets per guidelines
  • Screen for other diabetes complications

Recommendations

  1. 1.In individuals ≥15 years of age with type 1 diabetes, screening and evaluation for retinopathy by an expert professional should be performed annually starting 5 years after the onset of diabetes [Grade A, Level 1 (1,2)].
  2. 2.In individuals with type 2 diabetes, screening and evaluation for diabetic retinopathy by an expert professional should be performed at the time of diagnosis of diabetes [Grade A, Level 1 (3,4) ] and annually thereafter. The interval for follow-up assessments should be tailored to the severity of the retinopathy. In those with no or minimal retinopathy, the recommended interval is 1–2 years [Grade A, Level 1 (3,4)].
  3. 3.Screening for diabetic retinopathy should be performed by experienced professionals, either in person or through interpretation of retinal photographs taken through dilated pupils [Grade A, Level 1 (5)].
  4. 4.To prevent the onset and delay the progression of diabetic retinopathy, people with diabetes should be treated to achieve optimal control of blood glucose [Grade A, Level 1A (6,7) ] and BP [Grade A, Level 1A (8), for type 2 diabetes].
  5. 5.Though not recommended for CVD prevention or treatment, fenofibrate, in addition to statin therapy, may be used in patients with type 2 diabetes to slow the progression of established retinopathy [Grade A, Level 1A (9,10)].
  6. 6.Patients with sight-threatening diabetic retinopathy should be assessed by a general ophthalmologist or retina specialist [Grade D, Consensus]. Laser therapy and/or vitrectomy [Grade A, Level 1A (11-14) ] and/or pharmacological intervention [Grade A, Level 1A (15-18)] should be used.
  7. 7.Visually disabled people should be referred for low-vision evaluation and rehabilitation [Grade D, Consensus].

Abbreviations:
BP , blood pressure; CVD , cardiovascular disease.

References

  1. Klein R, Klein BE, Moss SE, Davis MD, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. IX. Four-year incidence and progression of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1989;107:237-43.
  2. Klein R, Klein BE, Moss SE, et al. The Wisconsin epidemiologic study of diabetic retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1984;102:520-6.
  3. Klein R, Klein BE, Moss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. X. Four-year incidence and progression of diabetic retinopathy when age at diagnosis is 30 years or more. Arch Ophthalmol 1989;107: 244-9.
  4. Klein R, Klein BE, Moss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. VII. Diabetic nonproliferative retinal lesions. Ophthalmology 1987;94:1389-400.
  5. Buxton MJ, Sculpher MJ, Ferguson BA, et al. Screening for treatable diabetic retinopathy: a comparison of different methods. Diabet Med 1991;8:371-7.
  6. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
  7. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352: 837-53.
  8. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703-13.
  9. Keech AC, Mitchell P, Summanen PA, et al. Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Lancet 2007;370:1687-97.
  10. Group AS, Group AES, Chew EY, et al. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med 2010;363: 233-44.
  11. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 1. Arch Ophthalmol 1985;103:1796-806.
  12. Photocoagulation treatment of proliferative diabetic retinopathy: the second report of diabetic retinopathy study findings. Ophthalmology 1978;85: 82-106.
  13. The Diabetic Retinopathy Vitrectomy Study Research Group. Early vitrectomy for severe vitreous hemorrhage in diabetic retinopathy. Four-year results of a randomized trial: Diabetic Retinopathy Vitrectomy Study Report 5. Arch Ophthalmol 1990;108:958-64.
  14. The Diabetic Retinopathy Vitrectomy Study Research Group. Early vitrectomy for severe proliferative diabetic retinopathy in eyes with useful vision. Results of a randomized trial: Diabetic Retinopathy Vitrectomy Study Report 3. Ophthalmology 1988;95:1307-20.
  15. Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE. Ophthalmology 2012;119:789-801.
  16. Mitchell P, Bandello F, Schmidt-Erfurth U, et al. The RESTORE study: ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology 2011;118:615-25.
  17. Pearson PA, Comstock TL, Ip M, et al. Fluocinolone acetonide intravitreal implant for diabetic macular edema: a 3-year multicenter, randomized, controlled clinical trial. Ophthalmology 2011;118:1580-7.
  18. Campochiaro PA, Brown DM, Pearson A, et al. Long-term benefit of sustaineddelivery fluocinolone acetonide vitreous inserts for diabetic macular edema. Ophthalmology 2011;118:626-35.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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