AOA practice guidelines for eye care in Diabetes

American Optometric Association has issued a clinical practice guideline regarding eye care of the patient with diabetes mellitus. It is of great relevance because of the increasing magnitude of incidence Eye Complications in Diabetes Mellitus.

Following are the major recommendations :

Diagnosis of Ocular Complications of Diabetes Mellitus

Ocular Examination in individuals with Undiagnosed Diabetes Mellitus

• The ocular examination of an individual suspected of having undiagnosed diabetes should include all aspects of a comprehensive eye examination* with supplemental testing, as noted in the original guideline document.


• Persons without a diagnosis of diabetes who present with signs suggestive of diabetes during the initial examination should be referred to their primary care physician for evaluation, or an A1C test or fasting blood glucose analysis may be ordered.

Ocular Examination in individuals with Diagnosed Diabetes Mellitus

• The ocular examination of a person with diabetes should include all aspects of a comprehensive eye examination,* with supplemental testing, as indicated, to detect and thoroughly evaluate ocular complications.


• Patients should be questioned about the awareness of their personal diabetes ABCs (A1C, blood pressure, and cholesterol levels and their history of smoking).

Ocular Examination

The initial ocular examination should include, but is not limited to, the following evaluations:

• Review of patient medical history


• Best-corrected visual acuity


• Pupillary reflexes


• Ocular motility


• Refractive status


• Confrontation visual field testing or visual field evaluation


• Slit lamp biomicroscopy


• Tonometry


• Dilated retinal examination

Dilated Retinal Examination

• Retinal examinations for diabetic retinopathy should be performed through a dilated pupil.


• When vitreous hemorrhage prevents adequate visualization of the retina, prompt referral to an ophthalmologist experienced in the management of diabetic retinal disease should be made for further evaluation.


• The individual's primary care physician should be informed of eye examination results following each examination, even when retinopathy is minimal or not present.

Ocular Examination Schedule in Persons with Diabetes Mellitus

• As diabetes may go undiagnosed for many years, any individual with type 2 diabetes should have a comprehensive dilated eye examination soon after the diagnosis of diabetes (American Diabetes Association, 2013).


• Individuals with diabetes should receive at least annual dilated eye examinations. The more frequent examination may be needed depending on changes in vision and the severity and progression of diabetic retinopathy.


• Women with pre-existing diabetes who are planning a pregnancy or who become pregnant should have a comprehensive eye examination prior to a planned pregnancy or during the first trimester, with follow-up during each trimester of pregnancy.

Ocular Examination Schedule in Persons with Non-retinal Ocular Complications of Diabetes Mellitus-Examination of persons with non-retinal ocular complications of diabetes should be consistent with current recommendations of care for each condition.

Ocular Examination Schedule in Persons with Retinal Complications of Diabetes Mellitus-Prompt referral to a vitreoretinal surgeon is indicated when a vitreous hemorrhage, a retinal detachment or other evidence of proliferative diabetic retinopathy is present.

Treatment and Management

Management of Ocular Complications of Diabetes Mellitus

Treatment in Persons with Non-retinal Ocular Complications

• Treatment protocols for persons with non-retinal ocular and visual complications should follow current recommendations for care and include education on the subject and recommendations for follow-up visits.


• As part of the proper management of diabetes, the optometrist should make referrals for concurrent care when indicated.

Treatment of Retinal Complications

• Laser Photocoagulation

Non-proliferative Diabetic Retinopathy (NPDR)-Panretinal photocoagulation (PRP) may be considered in patients with severe or very severe NPDR, or early proliferative diabetic retinopathy (PDR) with a high risk of progression (e.g., pregnancy, poor glycemic control, inability to follow-up, initiation of intensive glycemic control, impending ocular surgery, renal impairment and rapid progression of retinopathy) (Mohamed, Ross, & Chu, 2011). (A/A)

Proliferative Diabetic Retinopathy-Patients with high-risk PDR should receive referral to an ophthalmologist experienced in the management of diabetic retinal disease for prompt scatter PRP (Early Treatment Diabetic Retinopathy Study Research Group [ETDRS], 1991; Chew et al., 2003). (A/A; B/B)

Eyes in which PDR has not advanced to the high-risk stage should also be referred for consultation with an ophthalmologist experienced in the management of diabetic retinal disease (ETDRS, 1991; Chew et al., 2003). (A/A; B/B)

Following successful treatment with PRP, patients should be re-examined every 2 to 4 months. The follow-up interval may be extended based on disease severity and stability.

Diabetic Macular Edema (DME)-

• Following focal photocoagulation for DME, re-examination should be scheduled in 3 to 4 months.


• Patients with center-involved DME should be referred to an ophthalmologist experienced in the management of diabetic retinal disease for possible treatment.


• Individuals with DME, but without clinically significant macular edema (CSME), should be re-examined at 4- to 6-month intervals. Once CSME develops, treatment with focal laser photocoagulation or intravitreal anti-vascular endothelial growth factor (VEGF) injection is indicated (Mohamed, Ross, & Chu, 2011). (A/A)

Vitrectomy

• Eyes with vitreous hemorrhage (VH), traction retinal detachment (TRD), macular traction or an epiretinal membrane should be referred to an ophthalmologist experienced in the management of diabetic retinal disease for evaluation for possible vitrectomy.

Vascular Endothelial Growth Factor Inhibitors

The current standard of care for treatment of center-involved DME in persons with best corrected visual acuity of 20/32 or worse, is anti-VEGF injections (Diabetic Retinopathy Clinical Research Network, 2008; Diabetic Retinopathy Clinical Research Network et al., 2010). (A/A)

Patient Education

• Persons should be educated about the ocular signs and symptoms of diabetic retinopathy and other non-retinal complications of diabetes, and encouraged to comply with recommendations for follow-up eye examinations and care.


• Individuals should be advised of the risks of smoking related to diabetes and encouraged to quit smoking and/or seek smoking cessation assistance.


• Individuals should be educated about the long-term benefits of glucose control in saving sight, based on their individual medically appropriate A1C target.

Management of Persons with Visual Impairment

• Individuals who experience vision loss from diabetes should be provided, or referred for, a comprehensive examination of their visual impairment by a practitioner trained or experienced in vision rehabilitation.


• Persons with diabetes who experience visual difficulties should be counseled on the availability and scope of vision rehabilitation care and encouraged to utilize these services.


• Referral for counseling is indicated for any individual experiencing difficulty dealing with vision and/or health issues associated with diabetes or diabetic retinopathy. Educational literature and a list of support agencies and other resources should be made available to these individuals.

Read the full guideline click on the following link :https://www.aoa.org/documents/optometrists/CPG-1.pdf