RETINOPATHY

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RETINOPATHY

• 2003 Clinical Practice Guidelines
• for the Prevention and Management
• of Diabetes in Canada

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RETINOPATHY

• Diabetic retinopathy is the most common cause of
  new cases of legal blindness in North America in
  people of working age.
• The prevalence rate of proliferative retinopathy
  is 23 in people with type 1 diabetes and 3 - 14
  in people with type 2 diabetes.
• Patients with diabetes are also at increased risk
  of macular edema and cataracts.

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SCREENING

• The two main approaches to screening are
  ophthalmoscopy and retinal photography. The gold
  standard is 7-standard field stereoscopic-colour
  fundus photography.
• Ophthalmoscopy should be carried out by highly
  trained professionals through dilated pupils.
• The performance of mydriatic and nonmydriatic
  retinal photography depends on a number of
  factors including the number of photographic
  fields, resolution of the camera, ability of the
  professional who takes the images, and the
  ability of the professional who reads the images.

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SCREENING

• WHEN TO START
• At age 15 in type 1 with duration 5 years
• At diagnosis in type 2
• HOW
• 7-field stereo fundus photographs interpreted by
  a trained reader
• Direct ophthalmoscopy or slit-lamp fundoscopy
  through dilated pupil
• Digital fundus photography
• continued on next slide...

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SCREENING

• ...continued from previous slide
• IF RETINOPATHY IS PRESENT
• Diagnose severity and monitor at appropriate
  intervals (lt 1 year)
• Treat sight-threatening retinopathy with laser
  therapy
• Review glycemic, blood pressure and lipid control
  and adjust therapy to reach targets as per
  guidelines
• Screen for diabetes complications
• IF RETINOPATHY IS ABSENT
• Type 1 rescreen annually
• Type 2 rescreen in 1 - 2 years

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PREVENTION

• Predictors for the progression of retinopathy
  include more severe retinopathy, longer duration
  of diabetes, higher A1C, higher blood pressure,
  higher lipid levels and lower hematocrit.
• People with type 1 diabetes can delay the onset
  or slow the progression of retinopathy by
  improving glycemic control.
• People with type 2 treated intensively also show
  evidence of less retinopathy.
• Lowering blood pressure in both types of diabetes
  can prevent the development and progression of
  retinopathy.

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TREATMENT

• The following treatments have been shown to be
  effective for the following conditions
• Cataracts - cataract extraction
• Clinically significant macular edema - focal /
  grid laser photocoagulation
• Severe nonproliferative or proliferative
  retinopathy - scatter laser photocoagulation and
  vitrectomy
• Advanced active proliferative retinopathy
  unresponsive to laser photocoagulation - early
  vitrectomy

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RETINOPATHY- RECOMMENDATIONS

• In people with type 1 diabetes, screening and
  evaluation for retinopathy by an experienced
  professional should be performed annually 5 years
  after the onset of diabetes in individuals ? 15
  years of age Grade A, Level 1.
• In people with type 2 diabetes, screening and
  evaluation for retinopathy by an experienced
  professional should be performed at the time of
  diagnosis Grade A, Level 1. 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 to 2 years Grade A, Level 1.

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RETINOPATHY- RECOMMENDATIONS

• Screening for retinopathy should be performed by
  experienced professionals either in person or
  through their interpretation of photographs
  Grade A, Level 1.
• 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, blood pressure
  Grade A, Level 1A and lipids Grade D, Level 4.

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RETINOPATHY- RECOMMENDATIONS

• Patients with proliferative or severe
  nonproliferative retinopathy, vitreous hemorrhage
  or macular edema should be assessed by an
  ophthalmologist or retina specialist Grade D,
  Consensus and should be considered for laser
  therapy and/or vitrectomy Grade A, Level 1A.
• Visually disabled people should be referred for
  low-vision evaluation and rehabilitation Grade
  D, Consensus.