Diabetic Retinopathy Preferred Practice Pattern®

RETINA/VITREOUS PREFERRED PRACTICE PATTERN® DEVELOPMENT PROCESS AND PARTICIPANTS

The Retina/Vitreous Preferred Practice Pattern® Panel members wrote the Diabetic Retinopathy Preferred Practice Pattern® (PPP) guidelines. The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document.

Retina/Vitreous Preferred Practice Pattern Panel 2018–2019

Steven T. Bailey, MD, Retina Society Representative

Amani Fawzi, MD, Macula Society

FINANCIAL DISCLOSURES

In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx). relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at http://one.aao.org/CE/PracticeGuidelines/PPP.aspx). A majority (88%) of the members of the Retina/Vitreous Preferred Practice Pattern Panel 2018–2019 had no financial relationship to disclose.

TABLE OF CONTENTS

• OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P72

• METHODS AND KEY TO RATINGS P73

• HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P74

• INTRODUCTION P75

• Disease Definition P75

• Patient Population P75

• Clinical Objectives P75

• BACKGROUND P76

• Introduction P76

  • Prevalence of Diabetes P76

  • Prevalence of Diabetic Retinopathy P77

• Risk Factors P78

• Natural History P80

• CARE PROCESS P83

• Patient Outcome Criteria P84

• Diagnosis P84

  • History P84

  • Examination P84

  • Examination Schedule P85

  • Ancillary Tests P86

• Management P89

OBJECTIVES OF PREFERRED PRACTICE PATTERN® GUIDELINES

As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care.

The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical

METHODS AND KEY TO RATINGS

Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network¹ (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation² (GRADE) group are used. GRADE is a

HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE

The prevalence of diabetes is increasing with increasing industrialization and globalization. Consequently, the prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy is also expected to increase. Only about 60% of people with diabetes have recommended yearly screenings for diabetic retinopathy. Referral to an ophthalmologist is required when there is any evidence of diabetic retinopathy.

People with type 1 diabetes should have annual screenings for diabetic retinopathy

CARE PROCESS

The care process for diabetic retinopathy includes a medical history, a regular ophthalmologic examination or screening of high-quality retinal photographs of patients who have not had previous treatment for diabetic retinopathy or other eye disease, and regular follow-up. The purpose of an effective screening program is to determine who needs to be referred to an ophthalmologist for close follow-up and possible treatment, and who may simply be screened annually. Early detection of retinopathy

APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA

Providing quality care is the physician's foremost ethical obligation, and is the basis of public trust in physicians.

AMA Board of Trustees, 1986

Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of the patient. The discussion that follows characterizes the core elements of such care.

The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates compassion and concern for the individual, and utilizes

APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES

Diabetic retinopathy, which includes entities with the following ICD-9 and ICD-10 classifications (see Glossary):

APPENDIX 4. GLYCEMIC CONTROL

The Diabetes Control and Complications Trial (DCCT) was a multicenter, randomized controlled trial designed to study the connection between glycemic control and retinal, renal, and neurologic complications of type 1 diabetes mellitus. Published results from this trial demonstrated that improved blood sugar control can delay the onset and slow the progression of diabetic retinopathy, nephropathy, and neuropathy in type 1 patients.⁸¹ The DCCT showed a strong exponential relationship between the

APPENDIX 5. CLASSIFICATION OF DIABETIC RETINOPATHY IN THE EARLY TREATMENT OF DIABETIC RETINOPATHY STUDY

The Early Treatment of Diabetic Retinopathy Study (ETDRS) classification of diabetic retinopathy and definitions of macular edema are in Tables A6-1.

GLOSSARY

Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: A large multicenter clinical trial that evaluated intensive control of blood sugar, intensive control of blood pressure, and statin therapy (with or without fibrate treatment) for the prevention of cardiovascular disease events among high-risk patients with type 2 diabetes.

ACCORD: See Action to Control Cardiovascular Risk in Diabetes trial.

Anti-VEGF: See Anti-vascular endothelial growth factor.

Anti-vascular endothelial growth

LITERATURE SEARCHES FOR THIS PPP

Literature searches of the PubMed and Cochrane databases were conducted in April 2018; the search strategies are provided at www.aao.org/ppp. Specific limited update searches were conducted after June 2019.

(“Diabetic Retinopathy/epidemiology”[Mesh] OR “Diabetic

Retinopathy/ethnology “[Mesh])

(“Diabetic Retinopathy”[Mesh]) AND (“Risk Factors”[Mesh])

“Diabetic Retinopathy”[Mesh] AND “natural history”[tiab]

“Diabetic Retinopathy/diagnosis”[Mesh]

“Diabetic Retinopathy/therapy”[Mesh]

“Diabetic

RELATED ACADEMY MATERIALS

Basic and Clinical Science Course

Retina and Vitreous (Section 12, 2019–2020)

Clinical Statements –

Free download available at http://one.aao.org/guidelines-browse?filter=clinicalstatement.

Frequency of Ocular Examinations (2015)

International Clinical Classification System for Diabetic Retinopathy and Diabetic Macular Edema (2012) Screening for Diabetic Retinopathy (2014)

Telemedicine for Ophthalmology Information Statement (2018)

Verifying the Source of Compounded Bevacizumab for Intravitreal