CLINICAL Early DetectionGUIDELINES Saves Sight

Edition 4 :: May 2012

An initiative of Guide Dogs NSW/ACT and The University of New South Wales

DIABETIC RETINOPATHY
Evidence indicates that early detection of Diabetic Retinopathy (DR) by regular examination, is key to reducing vision loss and blindness from diabetes. Children with pre-pubescent diabetes onset should be screened at puberty, unless other considerations indicate the need for an earlier examination.

Imaging technology
The 2008 NHMRC Guidelines1 do not specifically recommend the use of imaging technologies, but do acknowledge their contribution in early diagnosis and monitoring. The Centre for Eye Health offers the following imaging modalities: Optomap widefield imaging Captures a single fundus image, encompassing up to 200 degrees of the retina. This can be obtained with undilated pupils, although pupil dilation usually improves the image quality. Optical Coherence Tomography (OCT) Provides optical-sections through the macula, retina or optic nerve head. OCT can provide information regarding macular thickness and localised areas of macular oedema, as well as haemorrhages, hard exudates, cotton wool spots and neovascularisation. Simultaneous stereo-photography Digital 3D images of the macula area can be obtained with the Kowa WX 3D cameras to assist in the detection of clinically significant macula oedema (CSME) and to provide baseline documentation of macular appearance to aid in future monitoring.

Risk factors
Age Type of diabetes (over the same duration, Type 1 may develop more severe DR compared with Type 2) Elevated HbA1c Duration of diabetes Systemic hypertension Hyperlipidaemia Renal disease Pregnancy (in women who had Type 1 or Type 2 diabetes prior to pregnancy) Family history of DR

Examination protocols
Visual acuity Measure this prior to pupil dilation. It should be noted that visual acuity may be unaffected, even in the presence of sight-threatening DR. Slit lamp examination To assess for iris neovascularisation. Pupil dilation^ This is a standard of care when examining patients with diabetes. Slit lamp fundoscopy and binocular indirect ophthalmoscopy (BIO) # The accepted routine practice is to perform this test after pupil dilation, using an appropriate lens (eg 90D or 78D for funduscopy; Panretinal or 20D lens for BIO). Fundus photography This can be used to supplement the findings of dilated fundus evaluation by further documenting the retinal appearance. Fundus photography can assist with future monitoring and to communicate with other health care practioners such as general practitioners, or ophthalmologists. Limitations of non-mydriatic and digital photography are outlined on pages 63, 64 and 67 of the 2008 NHMRC Guidelines1.

Examination frequency1
All patients with diabetes should have a dilated fundus examination and visual acuity assessment at least every two years. High risk patients without DR should be examined at least annually. This includes those with a longer duration of diabetes, poor glycaemic control, systemic hypertension, renal disease or hyperlipidaemia. Patients with non-proliferative diabetic retinopathy (NPDR) should be examined annually, or at 3 - 6 monthly intervals, depending on the DR level. All cases of mild or moderate NPDR should be followed closely to detect signs of sight-threatening retinopathy.* Pregnant women with diabetes should have a comprehensive eye examination in the first trimester. If DR is found, they need close follow-up throughout pregnancy. This does not apply to women who develop gestational diabetes. Women with gestational diabetes do not need ophthalmic surveillance after delivery, unless the diabetes persists.

Grading
The Modified Airlie House (Wisconsin) classification system (Table 1) has become the basis for detailed grading of DR. The ETDRS study quantified the risk of retinopathy progression, associated with individual retinal presentations, using the Wisconsin classification system2. The International Clinic Diabetic and Diabetic Macula Edema Disease Severity Scale (Table 2) has a modified classification system which emphasises the timeframe for referral, and elaborates on definitions for macula oedema.

High-risk patients without DR should be examined at least annually

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Table 1 : Classification of diabetic retinopathy into retinopathy stages (Wisconsin level) and predictive value of retinal lesions (adapted from Focal Points) Retinopathy Stage Definition Rate of progression (%) to PDR 1 year Minimal NPDR (level 20) Mild NPDR (level 35) Moderate NPDR (levels 43,47) Severe NPDR preproliferative (level 50+) PDR (level 60+) High-risk PDR (level 70+) Advanced PDR Macular Oedema Clinically significant Macular Oedema (CSME) Ma only Ma and one or more of: retinal haem, HEx, CWS, but not meeting Moderate NPDR definition H/Ma std photo 2A (Figure 1) in at least one quadrant and one or more of: CWS,VB, IRMA, but not meeting Severe NPDR definition Any of: H/Ma>std photo 2A in all four quadrants, IRMA >std photo 8A (Figure 2) in one or more quadrants,VB in two or more quadrants Any of: NVE or NVD <std photo 10A (Figure 3)w, vitreous/preretinal haem and NVE<1/2 disc area (DA) without NVD Any of: NVD>1/4 to 1/3 disc area, or with vitreous/preretinal haem, or NVE>1/2 DA with vitreous/preretinal haem High-risk PDR with tractional detachment involving macula or vitreous haem obscuring ability to grade NVD and NVE Retinal thickening wtihin two disc diameters of macula centre Retinal thickening within 500 of macular centre with adjacent thickening Can occur at any stage of DR Can occur at any stage of DR 5 12-26 52 3 years 14 30-48 71 not documented 1 8-18 15 46 15 25-39 56 75 to high-risk stage 1 year 5 years

Severe visual loss (VA6/240) develops in 25-40% within two years

FIGURE 1: STANDARD PHOTO 2A FROM THE WISCONSIN GRADING SYSTEM2,4

FIGURE 2: STANDARD PHOTO 8A FROM THE WISCONSIN GRADING SYSTEM2,4

FIGURE 3: STANDARD PHOTO 10A FROM THE WISCONSIN GRADING SYSTEM2,4

Referral criteria
Patients should be referred to an ophthalmologist urgently (within four weeks) if there is any unexplained fall in visual acuity. This is also the case if there is any suspicion of diabetic macular oedema (DME) or proliferative diabetic retinopathy (PDR). The international grading scale (Table 2) also contains recommended referral criteria.

Glossary
CSME : Clinically significant macular oedema (oedema abbreviated as E as in US literature.) CWS : Cotton wool spot DA: Disc area ETDRS : Early Treatment Diabetic Retinopathy Study H/Ma : Haemorrhages/ microaneurysms HbAIC : Haemoglobin AIC (glycosylated haemoglobin) Hex : Hard exudates IRMA : IntraRetinal microvascular abnormalities NPDR : Non-proliferative diabetic retinopathy NVD : New vessels on the (optic) disc NVE : New vessels elsewhere PDR : Proliferative diabetic retinopathy VB : Venous beading

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Table 2 : International Clinical Diabetic Retinopathy and Diabetic Macular Oedema Disease Severity Scales and Recommended Referral Patterns Retinopathy Stage Findings on ophthalmoscopy ETDRS Level Rate (%) of progression to PDR Early 1 year No apparent retinopathy Minimal NPDR Mild to moderate NPDR Severe NPDR No abnormalities Microaneurysms only More than just microaneurysms but less than severe NPDR Any of the following: More than 20 intraretinal haemorrhages in each of four quadrants Definite venous beading in two or more quadrants Prominent intraretinal microvascular abnormalities in one or more quadrant AND no signs of proliferative retinopathy One of the following: Neovascularisation Vitreous / preretinal haemorrhage No retinal thickening or hard exudates in posterior pole Mild - some retinal thickening or hard exudates in posterior pole but distant from the macula Moderate - retinal thickening or hard exudates approaching the centre of the macula but not involving the centre Laser treatment Severe - retinal thickening or hard exudates involving the centre of the macula Ophthalmology referral; consider laser Consider laser 10 20 35, 43, 47 53 A-E 5-26 52 14-48 71 1-8 17 7-24 44 Ophthalmology referral Ophthalmology referral 3 years High Risk 1 year 3 years Management

Proliferative DR

46 61,65,71 75,81,85

67

Ophthalmology referral; laser treatment

Macula Oedema Absent Present

Footnotes
* The 1997 NHMRC guidelines suggested that patients should be referred to ophthalmologists if DR greater than the presence of occasional microaneurysms was found. The latest guidelines suggest that whilst there doesnt appear to be any recent data to suggest that this timing needs changing, the NHMRC committee felt that because there is no clear evidence to support routine referral at a particular level of non-proliferative DR, the 1997 referral recommendation should no longer be used as a guideline. ^ 0.5 to 1.0% Tropicamide is safe and markedly increases the sensitivity of DR screening.The incidence of acute angle closure glaucoma from the use of mydriatic drops is rare, from 1 to 6 per 20,000 people. # Sensitivity of direct and indirect ophthalmoscopy is variable depending on the skill level of the examiner. Direct ophthalmoscopy is limited by weaknesses inherent in the instrument itself. This edition prepared by Paula Katalinic, Principal Staff Optometrist. Disclaimer: Although every care is taken by CFEH to ensure that this document is free from any error or inaccuracy, CFEH does not make any representation or warranty regarding the currency, accuracy or completeness of these Guidelines. Printed May 2012.

References
1. 2. 3. 4. NHMRC Guidelines for the Management of Diabetic Retinopathy. http://www.nhmrc.gov.au/_ files_nhmrc/publications/attachments/di15.pdf Fundus Photograph Reading Centre. Department of Ophthalmology & Vision Sciences University of Wisconsin Madison. http://eyephoto.ophth.wisc.edu/ResearchAreas.html Ginsburg, LH, Aiello LM. Diabetic reinopathy: classification, progression and management. Focal Points (AAO). 1993;XI:1-14. Davis, MD, Hubbard, LD, Trautman, J, Klein, R, Kroc. Collaborative Study Group. Studies of retinopathy: methodology for assessment and classification with fundus photographs. Diabetes. 1985; 34:42-49.

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