Comm Eye Health Vol. 28 No. 92 2015 pp 70 - 71. Published online 15 April 2016.
Diabetic retinopathy (DR): management and referral
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This diabetic retinopathy (DR) grading system is based on the International Council of Ophthalmology’s diabetic retinopathy and diabetic macular oedema disease severity scales. At whatever level you work, you must encourage everyone with diabetes to manage their blood sugar and blood pressure. Refer them to available services for help if they are not sure how to do this, or if their control is poor.
Diabetic retinopathy stage
No diabetic retinopathy
| Clinical signs | No abnormalities |
|---|---|
| What to do (screening/primary eye care) | Encourage patient to come again in 12 months |
| What to do (retinal clinic) | Review in 12 months |
| What you could say to your patients | Diabetes can affect the inside of your eyes at any time. It is important that you come back in twelve months so we can examine you again. This will help to prevent you losing vision or going blind. |
Mild nonproliferative diabetic retinopathy
| Clinical signs | Microaneurysms only |
|---|---|
| What to do (screening/primary eye care) | Encourage patient to come again in 12 months |
| What to do (retinal clinic) | Review in 12 months |
| What you could say to your patients | Your diabetes is affecting your eyes. At the moment your vision is good, but we must check your eyes in 12 months’ time to see if these changes are getting worse. If the damage becomes severe, we will need to treat your eyes to stop the diabetes affecting your sight. |
Moderate nonproliferative diabetic retinopathy
| Clinical signs | More than just microaneurysms but less than severe non-proliferative retinopathy |
|---|---|
| What to do (screening/primary eye care) | Encourage patient to come again in 6–12 months |
| What to do (retinal clinic) | Review in 6-12 months |
| What you could say to your patients | Your diabetes is damaging your eyes. At the moment your vision is good, but we must check your eyes in six months’ time as it is likely that these changes will get worse. If the damage becomes severe, we will need to treat your eyes to stop the diabetes affecting your sight. Unless you are treated promptly, you risk losing vision or going blind. |
Severe nonproliferative diabetic retinopathy
| Clinical signs | More than 20 haemorrhages in each quadrant; or venous beading in two quadrants; or intraretinal microvascular abnormalities (IRMA) |
|---|---|
| What to do (screening/primary eye care) | Refer to retinal clinic. All patients with severe non-proliferative DR should be in the care of an ophthalmologist. The patient should be re-examined every six months |
| What to do (retinal clinic) | Perform peripheral retinal photocoagulation if follow-up is unreliable; otherwise review in 6 months |
| What you could say to your patients | Your diabetes has damaged your eyes quite severely, although your vision is still good. You are likely to need treatment soon to ensure that you don’t lose vision or go blind. We must check your eyes in six months’ time. However, if you think you may not be able to come then, we may treat your eyes now, so we can be sure you don’t lose vision later. |
Proliferative diabetic retinopathy
| Clinical signs | Any new vessels at the disc or elsewhere, vitreous/ pre-retinal haemorrhage |
|---|---|
| What to do (screening/primary eye care) | Urgent referral to retinal clinic |
| What to do (retinal clinic) | Peripheral retinal photocoagulation or vitrectomy if there is vitreous haemorrhage or retinal detachment |
| What you could say to your patients | Your diabetes has damaged your eyes very severely. Although your vision may be good, you are at great risk of losing your sight over the next year. You need urgent treatment to save your sight. Treatment will not improve your eyesight, but should preserve the vision you have. |
MACULAR OEDEMA
Macular oedema absent
| Clinical signs | No exudates or retinal thickening in posterior pole |
|---|---|
| What to do (screening/primary eye care) | Review in 12 months |
| What to do (retinal clinic) | Review in 12 months |
| What you could say to your patients | As for "No diabetic retinopathy" above. |
Mild macular oedema
| Clinical signs | Exudates or retinal thickening at posterior pole, >1dd from fovea |
|---|---|
| What to do (screening/primary eye care) | Review in 6 months |
| What to do (retinal clinic) | Review in 6 months |
| What you could say to your patients | Your diabetes is damaging your eyes. At the moment your vision is good, but we must check your eyes in six months’ time as it is likely that these changes will get worse. If the damage becomes severe, we will need to treat your eyes to stop the diabetes affecting your sight. Unless you are treated promptly, you risk losing vision or going blind. |
Moderate macular oedema
| Clinical signs | Exudates or retinal thickening at posterior pole, 1dd or less from fovea, but not affecting fovea |
|---|---|
| What to do (screening/primary eye care) | Refer to retinal clinic. Encourage patient to manage their blood sugar and blood pressure, and refer them to available services for help if they are not sure how to do this |
| What to do (retinal clinic) | Laser treatment if clinically significant macular oedema (CSMO). Review in 6 months if no CSMO |
| What you could say to your patients | Your diabetes has damaged your eyes severely. Although your vision may be good at present, it is likely to get worse over the next year or two. You need laser treatment to stop your sight deteriorating. The treatment will not improve your eyesight, but should preserve the vision you have. |
Severe macular oedema
| Clinical signs | Exudates or retinal thickening affecting centre of fovea |
|---|---|
| What to do (screening/primary eye care) | Refer to retinal clinic |
| What to do (retinal clinic) | Laser treatment or intravitreal injections of anti-VEGF drugs |
| What you could say to your patients | You have probably noticed your eyesight has got worse. This is because your diabetes has damaged your eyes very severely. You need urgent treatment to prevent further loss of vision. The treatment may not improve your eyesight, but if you are not treated, your vision will get worse and you may even become blind. |
If you cannot see the retina due to cataract or vitreous haemorrhage, refer to an ophthalmologist for cataract surgery or a retinal surgeon for vitrectomy.:
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