Diabetic Retinopathy Grading

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Diabetic RetinopathyGrading Burden

• Dr John A. Olson
• MD FRCP
• Consultant Medical Ophthalmology
• Aberdeen Royal Infirmary

(Please use Notes Page view)
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Classification of Diabetic Retinopathy

• Non-Proliferative
• Proliferative
• Maculopathy

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Manual Grading

• Classical

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How Did We Get Here?

• DRS - does laser work ?
• ETDRS - when should it be applied ?
• But
• Pre- HBA1c
• Pre- Home glc monitoring

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Grading Today

• ETDRS
• EURODIAB
• 2 X 50 fields per eye
• Interim ETDRS grading
• Aldington 1995

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of Patients Developing PDR by severity of
Microaneurysms/Haemorrhage
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Cotton Wool Spots Exudates

• CWS
• in isolation, same risk of severe visual loss as
  exudates

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of Patients Developing PDR by severity of
Venous Beading
IRMA, see later
Retinal pallor indicating areas of extensive
capillary occlusion either side of beading
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of Patients Developing PDR by severity of IRMA
CWS
a
b
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New Vessels

• Presence
• Site
• Size
• Vitreous Haemorrhage
• ? 3 High Risk PDR

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Advanced DR

• Persistent Vitreous Haemorrhage
• Traction Retinal Detachment
• Rubeotic Glaucoma

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ETDRS Final Retinopathy Severity Scale
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Practical Retinopathy Severity Scale
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Risk of High Risk PDR
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Maculopathy
tide mark of exudates
Clinically Significant Macular Oedema (CSMO)
((grey patches)
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20/20 VisionCSMOETDRS
Geometric Centre NOT involved
Geometric Centre INVOLVED
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Grading Options For Screening

• Interim ETDRS
• DCCT
• WESDR
• EURODIAB
• Final ETDRS
• All current drug trials
• New Grading system
• Empirical
• Redefine

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Image Quality
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Red-free vs Colour

• Red-free
• Better contrast
• Haemorrhages
• IRMA
• VB
• NV

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The Burden

• Digital Camera
• Trained Graders
• Sensitivity 81-100
• Specificity 97-100

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21st Century Solution

• Automated grading willreduce the workload by 50

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The Advantages of being the Professor
Queens Anniversary Prizefor Medical Imaging
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The Eye Clinic may not be the best place
3 step deterioration in retinopathy
Cumulative incidence of laser
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Anyone can measureblood pressure
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Triage

• No/ Mild NPDR
• Annual review
• Mod/ Mod severe NPDR
• 6 monthly photography
• Dedicated Diabetes clinic
• ? Severe NPDR
• Ophthalmology referral

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Resources

• UK National Screening Committee's
  recommendations Preservation of Sight in
  Diabetes a risk reduction programme
• Health Authority 600,000
• 2.5 diagnosed with diabetes
• 85 initially attend
• 8 referred first year ( ? pre-proliferative)
• 3 by year 4
• Ad hoc schemes already reach 60 but sensitivity ?

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Ophthalmology Manpower

• 600,000
• 2.5
• 15,000 to screen
• 1020 new visits year 1
• 2 clinics a week
• 4 return clinics a week
• 420 year 4
• 1 clinic a week
• Nurse, Photographer, Optician,Secretary, Reception

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Laser Sessions

• 6 patients per session
• 5 of 12,000
• 250 sessions year 1
• 6 clinics a week !
• 117 year 4
• 2 clinics a week
• One WTE Ophthalmologist

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Only if carefully planned.Yes, but lets make
sure its the right difference.
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Will it be enough ?Will it make a difference ?