Managing diabetic retinopathy: ADA releases new position statement

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The American Diabetes Association has issued a position statement for managing diabetic retinopathy, as published in Diabetes Care.

The statement incorporates recent developments for diagnostic assessment and treatment options for clinicians and patients. These improvements include the widespread adoption of optical coherence tomography to assess retinal thickness and intraretinal pathology and wide-field fundus photography to reveal clinically silent microvascular lesions.

 

Factors that increase the risk of or are associated with diabetic retinopathy include chronic hyperglycemia, nephropathy, hypertension, and dyslipidemia, in addition to diabetes duration. Lowering blood pressure has been shown to decrease retinopathy progression in patients with type 2 diabetes. In individuals with dyslipidemia, retinopathy progression may be slowed by the addition of fenofibrate, particularly with very mild nonproliferative diabetic retinopathy (NPDR). Pregnancy in patients with type 1 diabetes may aggravate retinopathy and threaten vision, especially when glycemic control is poor at the time of conception.

The following statements outline the improvements in the natural history, screening, and treatment for diabetic retinopathy.

Natural History

  • Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy.

    • The UK Prospective Diabetes Study (UKPDS) of patients newly diagnosed with type 2 diabetes conclusively demonstrated that improved blood glucose control in those patients reduced the risk of developing retinopathy and nephropathy and possibly reduced the risk for neuropathy.

    • The overall microvascular complication rate was decreased by 25% in patients receiving intensive therapy of blood glucose control.

  • Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy.

    • The UKPDS showed a 37% reduction in microvascular abnormalities, including diabetic retinopathy and specifically diabetic macular edema (DME), with lowering of systolic blood pressure from a mean of 154 mm Hg to 144 mm Hg.

Screening

  • Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes.

  • Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of diabetes diagnosis.

  • If there is no evidence of retinopathy for one or more annual eye exams, then exams every 2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations for patients for type 1 or type 2 diabetes should be repeated at least annually by an ophthalmologist or optometrist.

    • If retinopathy is progressing or sight-threatening, then examinations will be required more frequently.

  • Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy.

  • Eye examinations should occur before pregnancy in the first trimester in patients with preexisting type 1 or type 2 diabetes.

    • These patients should then be monitored every trimester for 1 year post-partum as indicated by the degree of retinopathy.

  • While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional.

Treatment

  • Promptly refer patients with any level of DME, severe NPDR (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy to an ophthalmologist.

  • Laser photocoagulation therapy reduces the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe NPDR.

  • Intravitreous injections of antivascular endothelial growth factor are indicated for central involved DME, which occurs beneath the foveal center and may threaten reading vision.

  • The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage.

Reference

  1. Solomon SD, Chew E, Duh EJ, et al. Diabetic retinopathy: A position statement by the American Diabetes Association. Diabetes Care. March 2017. doi: 10.2337/dc16-2641