DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
C. Refer Patient with Type2 DM for Initial Eye Retinal Examination
OBJECTIVE
Establish the timing of the initial ocular evaluation for patients with type 2 DM.
BACKGROUND
Patients with newly diagnosed type 2 DM may have had several years of sub-clinical or clinical diabetes prior to
being diagnosed. Retinopathy can develop during this time and up to 40 percent of patients will have evidence of
diabetic eye disease at the time their diabetes is diagnosed. Although the prevalence of vision threatening
retinopathy at the time of diagnosis is very low, there is a 3-4 percent prevalence of proliferative retinopathy within
the first few years of disease. Consequently, it is recommended that patients with new onset type 2 DM who have
not had a dilated eye examination within the prior 12 months should have one performed within 6 months.
RECOMMENDATIONS
1. Patients who are newly diagnosed with type 2 DM and have not had an eye exam within the past 12 months
should have a retinal examination performed within 6 months [B]
2. A retinal examination (e.g. dilated fundus examination by an eye care professional or retinal imaging with
interpretation by a qualified, experienced reader) should be used to detect retinopathy. [A]
DISCUSSION
The quality of the eye examination is a critical factor in the ability to detect early retinopathy, thus only qualified
eye care professional or trained readers using validated imaging techniques should be utilized for retinopathy
screening and surveillance. Ophthalmoscopy should be performed through dilated pupils using high magnification
and stereo viewing. Fundus photography is also highly sensitive in detecting clinically significant retinopathy and
when combined with interpretation by an experienced reader, may exceed the sensitivity of ophthalmoscopy in
retinopathy detection. Non-mydriatic digital retinal imaging (i.e. fundus photography through a non-dilated pupil)
also provides excellent sensitivity. In some cases small pupils and/or media opacities will cause image degradation
(Whited et al., 2006). The combination of non-mydriatic digital retinal imaging with referral to an eye care specialist
for patients in whom image quality is sub-optimal is an appropriate screening strategy as it can achieve a very high
level of sensitivity in the detection of retinopathy. In some cases, selective use of mydriatic eye drops to facilitate
improved image quality will enhance the diagnostic utility of digital retinal imaging.
EVIDENCE TABLE
Recommendation Sources LE QE SR
1 Initial Screening for Retinopathy UKPDS 38 1998
I Fair B
in patients with Type 2 Diabetes Javitt et al., 1989, 1994, 1996
who have not had an eye exam
Nathan et al., 1991
within the past 12 months and
are newly diagnosed with type 2 Vijan et al., 2000
DM should have a retinal
examination performed within 6
months.
2 A retinal examination (e.g. dilated
fundus examination by an eye
care professional or retinal
imaging with interpretation by a
qualified, experienced reader)
should be used to detect
retinopathy.
Diabetic Retinopathy Study
Research Group 1981
ETDRS Research Group 1993
DCCT Research Group, 1993
Harding SP, BMJ 1995
I Good A
LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A)
Module E – Eye care Page 91