Professional Documents
Culture Documents
eye health
A guide for health
professionals
Contributors
A working group was convened to develop this Guide which included the following members:
Co-Chairs: Sehnaz Karadeniz and Paul Zimmet
Core Contributors: Pablo Aschner, Anne Belton, David Cavan, Atieno Jalango, Navleen Gandhi, Linda Hill, Lydia
Makaroff, Richard Le Mesurier, Bina Patel, Massimo Porta, Hugh Taylor.
The International Diabetes Federation and The Fred Hollows Foundation would also like to thank the following
contributors: Haslina Binte Hamzah, Muhammad Daud Khan, Ute Linnenkamp, Vanessa Luttermann, Tim Nolan,
Geneva Pritchard, Anna Saxby, Madeleine Smythe, Sara Webber, Wong Tien Yin.
Support
This publication was made possible with support from Bayer Pharma AG and Novartis Pharma AG.
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Screening and photo grading services, Indonesia. Photo: Dwi Ananta, HKI. CC BY-NC 2.0 CEHJ
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Table of contents
Foreword7
Executive summary 8
The purpose and scope of this document 9
What is diabetic eye disease? 10
Diabetes is increasing and so is diabetic eye disease 10
Managing diabetes to manage eye health 11
Keeping good eyes the key players 12
The financial and social burden of eye disease 13
Identifying diabetic eye disease 14
Managing diabetes for good eye health 16
Different types of diabetes and implications for eye health 18
Strategies to managing eye health 19
Detection of diabetic retinopathy 20
Grading of diabetic retinopathy and macular edema 22
Ophthalmic assessment of diabetic eye disease 25
Treatment of diabetic retinopathy by ophthalmologists 26
Post-treatment support 29
Everyone with diabetes is at risk of diabetic retinopathy 29
Appendix 1: Managing Eye Health in People with Diabetes 30
Appendix 2: Managing Diabetes for good eye health 32
Glossary 34
References36
Additional sources of information 38
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Foreword
Everyone with diabetes is at risk of losing for Diabetic Eye Care 2014 that set
vision. Good control of blood glucose, out the need for regular eye care from
blood pressure and blood lipids will reduce an ophthalmic perspective. The ICO
the annual incidence of eye disease and guidelines stress the need for a team
vision loss and will also prolong life. approach to the provision of care.
Timely treatment can prevent almost all This new Guide extends this approach
vision loss associated with diabetes and so to highlight what is needed from
regular eye exams become essential for all diabetologists, primary care practitioners
those living with diabetes. and others involved in the care of people
Regular eye screening begins with primary with diabetes.
health carers. There are only about The ICO is delighted to see this
200,000 ophthalmologists worldwide collaborative approach to the provision
and it would be impossible for them of eye care for those people living with
to undertake all the screening eye diabetes. We look forward to working
examinations required to detect those at with the International Diabetes Federation,
risk of vision loss and in need of treatment. The Fred Hollows Foundation, and others
Screening for diabetic eye disease needs in the eye health and diabetes sectors,
to become an integral part of the ongoing to promote the use of this Guide and to
primary care of those with diabetes with reduce the amount of blindness and vision
the establishment of well-defined referral loss from diabetes.
pathways for those needing further care.
This Guide builds on the guidelines Hugh R. Taylor AC MD
developed by the International Council President
of Ophthalmology (ICO) Guidelines International Council of Ophthalmology
The purpose of this document is to of people with diabetes, are most likely to
highlight for health professionals the rising have the opportunity to screen, educate
prevalence of diabetic-related eye disease, and support management of diabetic
particularly diabetic retinopathy, and eye disease. They can also facilitate
outline the important role and actions they timely referral to eye specialist services
can take to address it. for treatment to reduce sight loss. More
As the incidence of diabetes increases specialised eye health practitioners
worldwide, so does the incidence of its also have an important role however,
complications including diabetic eye as a relatively limited resource, they
disease. All patients with diabetes are at should focus on treatment rather than
risk of developing diabetic retinopathy. examination.
Diabetic retinopathy is the only eye Key actions by health professionals in
condition caused by diabetes; however managing eye health in people with
diabetes may exacerbate other eye diabetes include:
conditions such as cataract, glaucoma, Optimising control of blood glucose,
loss of focussing ability, and double vision. blood pressure and blood lipids in order
Diabetic retinopathy can cause blindness, to slow down the progression of diabetic
yet in most cases blindness is largely retinopathy
avoidable. The condition is often Ensuring that the person with diabetes
asymptomatic in its early stages and has regular eye exams and timely
regular eye examinations are the only treatment when required
way to determine the condition of the Educating and supporting the person
retina and take the appropriate action. with diabetes in managing their eye
Careful management of diabetes and health and their diabetes
early eye disease detection can help slow
Effective strategies in managing diabetes
costly and debilitating visual impairment
to reduce or stabilise vision loss are
and blindness. Maintaining good vision
through a combination of four key
requires optimising systemic factors (like
strategies: social support, nutritional
blood glucose, blood pressure and blood
support, medication, and medical
lipid control), regular eye checks and
examinations and treatment. The decision
timely referral for treatment.
to undergo treatment should be made
Primary health practitioners play a crucial in cooperation between the person with
role in all stages of managing good eye diabetes and the health professional1.
health by facilitating early diagnosis and
If diabetic retinopathy has been detected,
timely management of diabetic eye
referral to an ophthalmologist for timely
disease. Many people with diabetesas
treatment with laser photocoagulation and/
well as many health professionalsare
or intravitreal injections can prevent vision
unaware of the critical need to undergo
loss, stabilise vision, and in some cases
regular eye examinations. Primary health
even improve vision if performed early.
professionals, through their routine care
8 Diabetes eye health
The purpose and scope of this document
The worldwide rise of diabetes, and address it. By providing information about
its complications, means there is an eye disease as a potential complication
increasing need for health professionals of diabetes, this Guide aims to encourage
to consider the possibility of diabetic eye and facilitate early diagnosis and treatment
disease even before the symptoms begin of diabetic eye disease, in particular
to show. Early detection and treatment diabetic retinopathy, as well as to improve
of diabetic retinopathy can slow the care for people with diabetes through
deterioration of sight and reduce the encouraging integration and cooperation
burden of vision loss on individuals, across the health system.
their carers and society. Yet many The primary audience for this document
people with diabetesas well as many is the broad suite of health professionals
health professionalsare unaware of and care givers who care for people
the critical need to undergo regular eye with diabetes. This list includes primary
examinations. health practitioners, general practitioners,
The purpose of this Guide is to highlight endocrinologists, ophthalmologists and
for carers and health professionals the other eye care practitioners, nurses,
rising prevalence of diabetic-related eye diabetes educators and first contact health
disease, particularly diabetic retinopathy, providers.
and outline the actions they can take to
Participants in Trinidad, Tobago walk for sight on World Sight Day 2013 Photo: IAPB/VISION 2020. CC BY-NC 2.0 CEHJ
More than One in three living with diabetes will develop diabetic retinopathy
It is important to listen to the patients point of view. Bangladesh. Photo: Lutful Husain. CC BY-NC 2.0 CEHJ
Health professionals
Different health professionals play an
important role in managing diabetes,
screening for eye conditions and
supporting patients to manage their
own health conditions. Management of
diabetes and diabetic eye care requires
integration across the health care system.
In particular, access to more specialised
eye health expertise may be limitedeven
in developed countries, rural areas may be
underserviced by specialistsand so it is
important to consider how to make best
use of these resources or alternatives.
Patients wait for eye examination during community outreach. Democratic Republic of Congo.
Photo: Daniel Etyaale. CC BY-NC 2.0 CEHJ
A guide for health professionals
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Identifying diabetic eye disease
Haemorrhages
Central
Macula Retinal Vein Abnormal
Fovea growth of
Central
Optic blood
Retinal Artery
Disc vessels
Aneurysm
Retinal Hard Cotton
Arterioles Retinal Exudates wool spots
Venules
Metabolic control
Overall improved glycaemic control
can slow the progression of diabetic
retinopathy, especially when initiated soon
Clinical Tip: after the diagnosis of diabetes.
Communication principles
Control of other systemic factors
For all strategies, guiding principles for
communication are to: Medication such as anti-hypertensive and/
Ensure language used is accessible to or lipid-lowering drugs should be used
the person to treat hypertension and dyslipidaemia,
Provide information on consequences
and when combined with lifestyle change,
may slow the progression of diabetic
Jointly set person-centred goals
retinopathy.
When discussing treatment, health People may better adhere to regular eye
professionals should review with the examinations if you:
patient: Inform people with diabetes that eye
The costs and benefits of treatment examination is important even if their
What to expect during and after vision is not impaired
treatment Place reminders on a calendar or
The importance of continued eye medical record
examinations Acknowledge and discuss a fear of
The role the person can play in their blindness. This is one of the most
own self-management common fears and one reason why
people go into denial and do not seek
treatment
Ophthalmic staff preparing to see patients, Ethiopia. Photo: Lance Bellers/Sight Savers. CC BY-NC 2.0 CEHJ
Table 1 Timing of initial and ongoing eye examinations for people with diabetes
Eye
Type 1 diabetes Type 2 diabetes Gestational diabetes
Examination
Initial Initiate within five years Initiate as soon as Conduct on diagnosis of
examination after the diagnosis of possible after diagnosis gestational diabetes
diabetes of diabetes
If date of onset
unknown, assume that
the duration of diabetes
is more than five years
Children: five years after
diagnosis or at puberty,
whichever is the earlier
Ongoing Conduct regular examination every one to two No need for further
examinations years if no abnormality is detected examination if diabetes
resolves after delivery
Once retinopathy is detected, frequency of
assessments may need to increase depending on
severity of the retinopathy and level of control of
systemic risk factors. (See Table 5 Referral criteria
for people with type 1 diabetes and type 2 diabetes)
Retinal examination
Non-mydriatic Recommended as a screening method
retinal photography Provides a permanent record
Dilated pupils may improve sensitivity and image quality
Can be carried out using telemedicine
Or
Binocular indirect Pupils must be dilated
ophthalmoscopy Large field view
Can be combined with slit-lamp examination to examine peripheral
retina
Or
Mydriatic retinal Pupils must be dilated
photography Provides a permanent record
(conventional
Sensitive method
fundus camera)
Can be carried out using telemedicine
Or
Slit-lamp Used in routine clinical practice
biomicroscopy Pupils must be dilated for fundus examination
Evaluation of the anterior and posterior segment with contact/
noncontact lenses
Clinical Tip:
Pupil dilation
Repeat examination
Repeat examination
in one to two years
Referral within four
No referral
months
months
Sudden severe vision loss
Retinal tear and/or detachment
Proliferative diabetic retinopathy
Severe DME
Unexplained gradual worsening of
vision
Visual acuity below 6/12 (20/40)
Symptomatic vision complaints
Unexplained retinal findings
Visual acuity cannot be obtained
Retinal examination cannot be obtained
Previous laser or anti-VEGF treatment
Glaucoma
Cataract
Inability to visualise fundus
Severe non-proliferative diabetic
retinopathy
DME without centre involvement
Moderate non-proliferative diabetic
retinopathy (no DME)
Mild non-proliferative diabetic
retinopathy
No apparent diabetic retinopathy
A photographer working with a mobile clinic team takes fundus images in a rural hospital.
Photo: Cristvo Matsinhe. CC BY-NC 2.0 CEHJ
Vitrectomy
Purpose Can repair or prevent traction retinal detachment and tears, reduce severe
vitreous haemorrhage, and reduce neovascularisation that continues despite
repeated laser treatment
Indications Severe vitreous haemorrhage of one to three months that does not clear
spontaneously
Advanced active proliferative DR that persists despite laser treatment
Tractional retinal detachment involving/threatening the macula
Combined traction-rhegmatogenous retinal detachment
Tractional macular edema or epiretinal membrane involving the macula
Mode of Removal of the vitreous gel, abnormal vessels, fibrous proliferations
operation
Procedure Performed under local or general anaesthesia
Surgeon inserts instruments into the eye and removes vitreous gel and fibrous
tissue; flattens retina and repairs retinal tears
Follow-up One week, one month, three months and every six months thereafter, if not
indicated otherwise
Potential Retinal detachment
complications High intraocular pressure
Cataract
Eye screening
a. Visual acuity test: using acuity lane
and a high-contrast visual acuity chart.
Alternatively, a near or distance eye
chart and a pin-hole option to see
if visual acuity is reduced. If visual
acuity below 6/12 (20/40), refer to eye
specialist
b. Retinal examination adequate for
diabetic retinopathy classification
(see next page)
Moderate non-proliferative
diabetic retinopathy
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Healthy lifestyle
Action by health professionals
Nutrition Provide meal planning advice Provide advice on healthy nutrition
Teach how to match carbohydrate as soon as possible after diagnosis of
intake to insulin doses and how to diabetes
adjust insulin for daily life
Action by people with type 1 diabetes Action by people with type 2 diabetes
Physical Measure blood glucose before, during Gradually increase physical activity,
activity and after exercise taking into consideration ability and
Be prepared to treat hypoglycaemia specific goals
May need to adjust food and insulin Adjust medication and/or carbohydrate
intake according to physical activity
Seek a medical review before starting
exercise programmes
Low If glucose monitoring is not possible,
resource people with type 1 diabetes should have
setting a snack and/or reduce their insulin dose
before physical activity
Smoking Strongly encourage smoking cessation Strongly encourage smoking cessation
D Dyslipidaemia G Glucose
Dyslipidaemia is abnormal levels of fats Glucose is the major source of energy
(lipids) in the blood. for living cells produced in the body
from proteins, fats and carbohydrates.
E Endophthalmitis It is carried to each cell through the
Endophthalmitis is an inflammatory bloodstream. However, the cells
condition of the aqueous and/or cannot use glucose without the help
vitreous humour, which is usually of insulin.
caused by infection.
Glycosylated haemoglobin (HbA1c)
F Fluorescein angiography Glycosylated or glycated haemoglobin
Fluorescein angiography is used to is a test that gives a representation
examine blood vessels in the retina. of the average blood glucose level
A fluorescent dye is injected into a vein over a three-month period, and gives
in the arm and images are taken as the an indication of the overall level of
dye passes through the blood vessels diabetic control.
in the eye.
Gonioscopy
Fundus Gonioscopy is the examination of the
The fundus is the part of the eye angle of the anterior chamber of the
opposite the lens. It includes the eye with a gonioscope.
retina, optic nerve head (optic disc),
macula and fovea. The fundus can be H Hyperglycaemia
examined by ophthalmoscopy and/or Hyperglycaemia is a raised level of
fundus photography. glucose in the blood. It occurs when
the body does not have enough insulin
Fundus photography or cannot use the insulin it does have
When performing ophthalmic fundus to turn glucose into energy.
photography, the pupil is dilated with
eye drops and a special camera is used Hypertension
to focus on the fundus. This painless Hypertension is persistently elevated
procedure produces a sharp view of blood pressure.
the retina, the retinal vasculature and
the optic nerve head (optic disc) from
which the retinal vessels enter the eye.
The resulting images show the optic
nerve through which visual signals
are transmitted to the brain and the
retinal vessels that supply nutrition and
oxygen to the tissue. Ophthalmologists
use these retinal photographs to
diagnose and treat eye diseases.
M Macula
The macula is located roughly in
the centre of the retina. It is a small
and highly sensitive part of the retina
responsible for detailed central vision.