Clinical Practice Guidelines
Retinopathy

https://doi.org/10.1016/j.jcjd.2013.01.038Get rights and content

Introduction

Diabetic retinopathy is the most common cause of new cases of legal blindness in people of working age (1). The Eye Diseases Prevalence Research Group determined the crude prevalence rate of retinopathy in the adult population with diabetes of the United States to be 40.3%; sight-threatening retinopathy occurred at a rate of 8.2% (1). Previous data showed the prevalence rate of proliferative retinopathy to be 23% in people with type 1 diabetes, 14% in people with type 2 diabetes and on insulin therapy, and 3% in people receiving oral antihyperglycemic therapies (2). Macular edema occurs in 11%, 15% and 4% of these groups, respectively (3). Higher prevalence rates were noted in First Nations populations in Canada 4, 5.

Visual loss is associated with significant morbidity, including increased falls, hip fracture and a 4-fold increase in mortality (6). Among individuals with type 1 diabetes, limb amputation and visual loss due to diabetic retinopathy are the independent predictors of early death (7).

Section snippets

Definition and Pathogenesis

Diabetic retinopathy is clinically defined, diagnosed and treated based on the extent of retinal vascular disease exclusively. Three distinct forms of diabetic retinopathy are described: 1) macular edema, which includes diffuse or focal vascular leakage at the macula; 2) progressive accumulation of blood vessel change that includes microaneurysms, intraretinal hemorrhage, vascular tortuosity and vascular malformation (together known as nonproliferative diabetic retinopathy) that ultimately

Screening

Because laser therapy for sight-threatening diabetic retinopathy reduces the risk of blindness, ophthalmic screening strategies are intended to detect disease treatable by this modality 8, 9, 10, 11. Sight-threatening diabetic retinopathy includes severe nonproliferative diabetic retinopathy, proliferative diabetic retinopathy or clinically significant macular edema (CSME) (8), a strictly defined form of diabetic macular edema (DME) that relies on the clinical assessment of retinal thickening

Delay of Onset and Progression

Risk factors for the development or progression of diabetic retinopathy are longer duration of diabetes, elevated glycated hemoglobin (A1C), increased blood pressure (BP), dyslipidemia, low hemoglobin level, pregnancy (with type 1 diabetes), proteinuria and severe retinopathy itself 14, 15, 16, 17, 19, 25, 26, 27, 28, 29, 30, 31.

Treatment

Treatment modalities for diabetic retinopathy include retinal photocoagulation, intraocular injection of pharmacological agents and vitreoretinal surgery.

Other Relevant Guidelines

Targets for Glycemic Control, p. S31

Dyslipidemia, p. S110

Treatment of Hypertension, p. S117

Type 1 Diabetes in Children and Adolescents, p. S153

Type 2 Diabetes in Children and Adolescents, p. S163

Diabetes and Pregnancy, p. S168

First page preview

First page preview
Click to open first page preview

References (66)

  • A.C. Keech et al.

    Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial

    Lancet

    (2007)
  • K. Bergerhoff et al.

    Aspirin in diabetic retinopathy. A systematic review

    Endocrinol Metab Clin North Am

    (2002)
  • L.P. Aiello et al.

    Systemic considerations in the management of diabetic retinopathy

    Am J Ophthalmol

    (2001)
  • E.Y. Chew et al.

    The long-term effects of laser photocoagulation treatment in patients with diabetic retinopathy: the early treatment diabetic retinopathy follow-up study

    Ophthalmology

    (2003)
  • Q.D. Nguyen et al.

    Ranibizumab for diabetic macular edema: results from 2 phase iii randomized trials: RISE and RIDE

    Ophthalmology

    (2012)
  • P. Mitchell et al.

    The RESTORE study: ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema

    Ophthalmology

    (2011)
  • M.J. Elman et al.

    Expanded 2-year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema

    Ophthalmology

    (2011)
  • P.A. Pearson et al.

    Fluocinolone acetonide intravitreal implant for diabetic macular edema: a 3-year multicenter, randomized, controlled clinical trial

    Ophthalmology

    (2011)
  • W.E. Smiddy et al.

    Vitrectomy in the management of diabetic retinopathy

    Surv Ophthalmol

    (1999)
  • G.E. Fonda

    Optical treatment of residual vision in diabetic retinopathy

    Ophthalmology

    (1994)
  • J.H. Kempen et al.

    The prevalence of diabetic retinopathy among adults in the United States

    Arch Ophthalmol

    (2004)
  • R. Klein et al.

    Epidemiology of proliferative diabetic retinopathy

    Diabetes Care

    (1992)
  • H. Kaur et al.

    The current status of diabetes care, diabetic retinopathy screening and eye-care in British Columbia's First Nations Communities

    Int J Circumpolar Health

    (2004)
  • D. Maberley et al.

    Screening for diabetic retinopathy in James Bay, Ontario: a cost-effectiveness analysis

    CMAJ

    (2003)
  • H.T. Vu et al.

    Impact of unilateral and bilateral vision loss on quality of life

    Br J Ophthalmol

    (2005)
  • M. Cusick et al.

    Associations of mortality and diabetes complications in patients with type 1 and type 2 diabetes: early treatment diabetic retinopathy study report no. 27

    Diabetes Care

    (2005)
  • Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Early Treatment Diabetic Retinopathy Study Research Group

    Arch Ophthalmol

    (1985)
  • F.L. Ferris

    How effective are treatments for diabetic retinopathy?

    JAMA

    (1993)
  • Photocoagulation treatment of proliferative diabetic retinopathy: the second report of diabetic retinopathy study findings

    Ophthalmology

    (1978)
  • F. Ferris

    Early photocoagulation in patients with either type I or type II diabetes

    Trans Am Ophthalmol Soc

    (1996)
  • N. Younis et al.

    Incidence of sight-threatening retinopathy in Type 1 diabetes in a systematic screening programme

    Diabet Med

    (2003)
  • R. Klein 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)
  • R. Klein 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)
  • Cited by (0)

    View full text