ICO GUIDELINES FOR DIABETIC

EYE CARE
Updated 2017
 Introduction
A specific microvascular complication of
DM

Affects 1in 3 person with DM

Leading cause of vision loss in working

adult

Poor quality of life, reduced levels of

physical, emotional, and social well being
 Classification
• Microaneurysm, haemorrhage, venous
NPDR beading, intraretinal microvascular
abnormalities, exudates, cotton wool spots,

• Retinal neovascularization is typical

PDR characteristic
• Could be NVD or NVE

• Assessed separately from the stages of

DME retinopathy
• Can be found in any DR severity
 Screening Guidelines

The screening • Presenting visual acuity examination using a near or

distance eye chart and a pin-hole
vision exam • Refracted visual acuity examination

• Direct or indirect ophthalmoscopy or slit-lamp

A retinal biomicroscopic examination of the retina.
• Fundus photography
examination • optical coherence tomography (OCT) scanning

• Blood glucose
• Blood pressure
History • Serum lipids
• Women should be asked about pregnancy
 Detailed Assessment of Diabetic
Retinopathy
Initial Physical Exam (Key
Patient History
Elements)
• Duration of diabetes • Visual acuity
• HbA1c • Measurement of IOP
• Medications • Gonioscopy when
• Systemic history indicated
• Ocular history • Slit-lamp biomicroscopy
• Fundus examination
• Fundus Photo, OCT
 Follow Up Examination of Diabetic
Retinopathy
Follow-up Physical
Follow-up History
Exam
• Visual symptoms • Visual Acuity
• Glycemic status • Measurement of IOP
(hemoglobin A1c) • Gonioscopy when
• Systemic status (e.g., indicated
pregnancy, blood • Slit-lamp
pressure, serum lipid biomicroscopy
levels, renal status) • Fundus examination
 Ancillary Tests (High Resource
Settings)
• Provide quantitative assessment of DME
• Useful in locating the area with retinal thickening;
OCT • detailing the types of DME as diffuse, cystic changes,
sub-retinal fluid/detachment, and vitreoretinal traction.

Fundus • recording the disease activity

• Useful in determining detailed severity of the disease.
photo

Fluorescein • Retinal non-perfusion area, presence of retinal

neovascularization,
• microaneurysms or macular capillary non-perfusion in
angiography DME.
Treatment of Diabetic Retinopathy
• Optimize medical treatment:
– Improve glycemic control (HbA1c), systemic hypertension and
dyslipidemia.
• No DR, Mild or Moderate NPDR:
– Follow recommended intervals for examination.
• Severe NPDR:
– Follow closely for development of PDR.
– Consider early panretinal photocoagulation for patients at high risk of
progression to PDR or poor compliance with follow-up.
– Other factors, such as poor compliance, impending cataract extraction
or pregnancy, and status of fellow eye will also help in determining the
timing of the panretinal photocoagulation.
• PDR:
– Panretinal photocoagulation (PRP)
– Anti-VEGF injections are effective against retinal neovascularization.
 Technique for PRP
• Fully dilated and topical anesthesia is used
• Typical initial settings on the Argon laser would be 500 μm spot size, a 0.1 second
exposure and 250-270 mw power. The power is gradually increased until a whitish
reaction is obtained on the retina. The lesions are placed 1 burn width apart
• A total of 1600-3000 burns are placed in 1 or more sittings, carefully avoiding the
macular area and any areas of tractional elevation of the retina
• The burns are placed 2 to 3 disc diameters away from the center of the macula
and 1 disc diameter away from the disc, usually outside the arcades and extended
peripherally up to the equator and beyond.
• Laser treatment should not be applied over major retinal veins, preretinal
hemorrhages, darkly pigmented chorioretinal scars, or within 1 DD (200-300 μm)
of center of macula,
• Favor quadrants with active new vessels or areas with intraretinal microvascular
abnormalities where scars are more widely spaced and areas of severe ischemia
not previously treated, such as the temporal part of the posterior pole.
 Treatment for Diabetic Macular Edema
(DME)
• Optimize medical treatment:
– Improve glycemic control (HbA1c), systemic hypertension , and dyslipidemia.
• DME without central involvement:
– May observe until there is progression to central involvement
– Consider focal laser to leaking microaneurysms if thickening is threatening the fovea
• Central-involved DME and good visual acuity (better than 6/9 or 20/30): 3 treatment
options being evaluated in an ongoing clinical trial:
– Careful follow-up with anti-VEGF treatment only for worsening DME
– Intravitreal anti- VEGF injections
– Laser photocoagulation with anti-VEGF
• Central-involved DME and associated vision loss (6/9 or 20/30 or worse):
– intravitreal anti-VEGF treatment
– Patients should be monitored monthly with OCT to consider the need for treatment.
• DME associated with proliferative DR:
– Monotherapy with intravitreal anti-VEGF therapy
– should be considered with re-evaluation for PRP versus continued anti-VEGF once the DME
resolves.
• Vitreomacular traction or epiretinal membrane on OCT:
– Pars plana vitrectomy