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

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
D. Follow-Up Examination Yearly Or According To Eye Care Provider-Recommended Schedule
OBJECTIVE
Establish a follow-up interval for patients based on the risk for retinopathy development or progression.
RECOMMENDATIONS
1. Patients who have had no retinopathy on all previous examinations should be screened for retinopathy at
least every other year (biennial screening). More frequent retinal examinations in such patients should be
considered when risk factors associated with an increased rate of progression of retinopathy are present. [B]
2. Patients with existing retinopathy should be managed in conjunction with an eye care professional and
examined at intervals deemed appropriate for the level of retinopathy. [I]
DISCUSSION
The inability of symptoms alone to accurately predict the presence or severity of retinopathy necessitates regularly
scheduled retinal examinations for patients with diabetes. Some patients will remain retinopathy-free for several
years, but the course of diabetic eye disease cannot be reliably predicted for a given individual. Risk factors for
progression of retinopathy include: poorly controlled HbA 1 c (e.g. >9.0), rapid and substantial HbA 1 c improvement
(a decrease of approximately 2% or greater over 160 mm Hg). In light of these associations, it is
prudent to perform more frequent retinal examinations in such patients. Clinicians should exert caution in extending
biennial examinations to patients with factors associated with a higher likelihood of retinopathy progression.
Duration of disease is most strongly associated with retinopathy in individuals with type 1 DM. The prevalence of
proliferative retinopathy approaches 30% after 15 years of diabetes and may rise to as much as 50% after 20 years.
Although the prevalence of proliferative disease is lower in type 2 diabetes, the prevalence of any retinopathy
approaches 75% in insulin-treated patients with longer duration of diabetes and the prevalence of proliferative
retinopathy may exceed 20%. Different patients may exhibit separate and unique rates of retinopathy development
or progression, but the likelihood of ocular involvement increases with duration of diabetes.
Macroalbuminuria (i.e. nephropathy) and lower extremity amputation are also associated with the presence of
retinopathy. Although the relationship may not be causal, these patients typically have long-standing or advanced
complications from diabetes and are likely to have other evidence of microvascular disease.
Pregnancy may be associated with rapid deterioration of existing retinopathy and a higher risk of progression to
vision threatening disease. A woman with pre-existing diabetes who becomes pregnant should be examined at the
time of diagnosis and if she has greater than minimal retinopathy, repeat examinations should be performed at 4-6
week intervals. Proliferative retinopathy or clinically significant macular edema should be treated promptly. Those
with less severe retinopathy should be monitored closely throughout their pregnancy (i.e. during each trimester). In
the absence of an eye examination within the previous twelve months, patients who are pregnant should have an
expedited appointment for a retinopathy evaluation. In addition, regardless of the timing of the last eye examination,
the patient’s eye care provider should be notified of the pregnancy.
Retinopathy of any level can progress rapidly over the course of a year and occasionally even mild retinopathy will
progress to proliferative retinopathy within that time frame. As follow-up intervals shorter than 12 months may be
indicated for some of these individuals, patients with retinopathy who have not had a retinal exam within the
previous year should be referred for an expedited retinal evaluation. Patients who have previously undergone laser
therapy have already reached the stage of vision threatening diabetic eye disease. These patients require close follow
up and in the absence of information to the contrary should be considered at high risk for vision loss and receive an
expedited examination if they have not had one within the previous year.
Module E – Eye care Page 92