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Diabetes - Screening and Management of Eye Complications

Diabetes - Screening & Management of Eye Complications

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Introduction

Diabetic retinopathy is the commonest cause of blindness in patients of working age in the UK.

The risk of developing retinopathy can be reduced by good control of diabetes and blood pressure. Early stages can be symptom free and therefore regular screening is essential to prevent blindness. Cataracts are also more common in diabetes and will be detected by screening.

* Early Detection may save sight *

All newly diagnosed patients with diabetes should be referred to the Bedfordshire Diabetic Retinal Screening Service - (Referral Form see - Useful Resources and Links)

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Stages of Retinopathy

Background Retinopathy

Background retinopathy is very common occurring in 95% of patients with Type 1 Diabetes after 15 years and about 65% of patients with Type 2 Diabetes after 15 years. Two years after diagnosis it is found in about 2% of patients with Type 1 Diabetes and 25% of patients with Type 2 Diabetes. Type 2 Diabetes may present with retinopathy.

Background retinopathy is characterised by 'dots & blots' on the retina; microaneursyms, exudates and haemorrhages. Minor degrees of retinopathy may not be clinically important but may progress to sight threatening retinopathy: regular screening is essential

Maculopathy

If retinopathy affects the macula then central vision may be destroyed. Maculopathy may take a number of forms: macular oedema and exudative maculopathy are the most common forms. Macular oedema may be difficult to see with the ophthalmoscope and should be suspected if there is an unexplained fall in visual acuity. If maculopathy is suspected then an urgent ophthalmological referral should be made.

Proliferative Retinopathy

Proliferative retinopathy involves the growth of new blood vessels out of the retina: these are fragile and may bleed causing vitreous haemorrhage and eventual retinal detachment. Urgent laser treatment may be necessary to preserve sight.

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Retinal Screening

Eye screening for adults newly diagnosed with diabetes should be started from diagnosis.

Depending on the findings, initial eye screening should be followed by:

routine review in 1 year, or

earlier review, or

referral to an ophthalmologist.

Retinal screening has to be undertaken by a quality assured structured programme which meets national standards.

This is provided locally by the Bedfordshire Diabetic Retinopathy Screening Service using digital retinal photography.

Visits to the optometrist for other essential checks need to be in addition to regular attendance at eye screening. Examination at an optometrist locally does not replace the need for formal retinal screening.

The following pathway comes from the National Screening Committee workbook on Retinopathy Screening and is an attempt to link the NSC and NICE recommendations on retinal screening.

 

On diagnosis of type 1 or type 2 diabetes, refer for screening; if symptomatic use clinical judgment for direct referral to ophthalmology.

 
 

Retinal screening will include:

 
 

Best corrected visual acuity, with spectacles or pinhole as appropriate

 
 

Dilation of pupils and digital retinal photography

 
Patients who either cannot be screened with a camera or whose retinopathy is such that they do not currently need treatment but who need more frequent surveillance than annual screening will be managed in new Surveillance Clinics from January 2014. These will be managed by the retinal screening programme under ophthalmological supervision.
 

OPDR- Ophthalmic Photographic Diabetic Retinopathy Clinics. These will provide more frequent supervision when the clinical lead considers that images taken do not require referral to the HES (Hospital Eye Service) but are in need of more frequent screening than annual screening. This pathway will include pregnant diabetic patients who need to be screened more often than annually during their pregnancy (NICE guidelines).

 

SLB- Slit Lamp Biomicroscopy Clinics . These will provide an alternative examination technique for patients where adequate retinal images cannot be obtained by photography such as cataracts or other reasons which cause opacity. This clinic will run by an optometrist under the supervision of the Clinical Lead. Patients will be kept under this pathway unless they require referral to the HES.

Retinal Grading Scheme

R

NHS Diabetic Eye Screening Programme Feature Based Grading Classification

RO

None No DR Routine Diabetes Care Annual screening

R1

Background 1 micro aneurysm *
2 micro aneurysms
3 micro aneurysms
4 micro aneurysms
5+ micro aneurysms
or
micro aneurysm (s)

retinal haemorrhage(s)
venous loop
any exudate in the presence of other features of DR
Any number of cotton wool spots (CWS) in the presence of other features of DR
Routine diabetes care
Annual screening
 

R2

Pre-proliferative Venous beading

Venous reduplication
Multiple blot haemorrhages
Intraretinal microvascular abnormality (IRMA)
Routine referral to HES
Achievable < 13 weeks
 

R3

Proliferative Stable pre-retinal fibrosis + peripheral retinal scatter laser
Stable fibrous proliferation (disc or elsewhere) + peripheral retinal scatter laser
R3s (Stable post treatment)

(If discharged from the Hospital Eye Service a photograph should be taken at or shortly after discharge from the Hospital Eye Service (HES) that records these features)

 

R3S (Stable) R1 features (from feature based grading) + peripheral retinal scatter laser

 

R3A (Active) new vessels on disc (NVD)
new vessels elsewhere (NVE)
New pre-retinal or vitreous haemorrhage
New pre-retinal fibrosis
New tractional retinal detachment
Reactivation in a previous stable R3s eye
R3a (Active Proliferative Retinopathy)

Refer to HES < 2weeks
 

M

  Maculopathy  

M0

  No maculopathy absence of any M1 features
 

M0 

 

  Any micro aneurysm or haemorrhage within 1DD of the centre of the fovea if associated with a best VA of ≤ 6/12 where the cause if the reduced vision is known and is not diabetic macular oedema

M1

  Exudate within 1 disc diameter (DD) of the centre of the fovea
Group of exudates within the macula
Retinal thickening within 1DD of the centre of the fovea (if stereo available)
Any micro aneurysm or haemorrhage within 1DD of the centre of the fovea only if associated with a best VA of ≤ 6/12 (if no stereo)
Refer to HES / OPDR
<13 weeks

 

P

  Photocoagulation  

P0

  No evidence of previous photocoagulation (default)
 

 

P1

  Focal/grid to macula or peripheral scatter
 

U

  Ungradable
An image set that cannot be graded
Refer to HES /SLB
 

 

Other Lesions
(optional)
Non DR Features
 
Local Protocols.
* dot haemorrhages should be included in the count as it is often difficult to tell the difference between a micro aneurysm and a dot haemorrhage
 

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Useful External Links & Resources
PDF File

PALS | Information Leaflet - Retinal Screening Service in Bedfordshire

PDF File

PALS | Information Leaflet - Diabetic Retinopathy: The Facts

PDF File

Diabetic Retinopathy Screening Referral Form

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