Algorithm for Screening of International Clinical Diabetic Retinopathy

Diabetic Retinopathy to Prevent Blindness and Diabetic Macula Oedema Disease Severity Scale Recommended Follow-up Schedule
Retinopathy Stage Findings on Ophthalmoscopy Stage of Retinopathy Follow-Up
No DR 12 - 24 months
Register all patients with diabetes No apparent
No abnormalities Mild NPDR without maculopathy 9 - 12 months
retinopathy
Moderate NPDR without maculopathy 6 months
Mild non-proliferative Mild/Moderate NPDR with maculopathy
Microaneurysms only
DR (NPDR)
Assess and record visual acuity (VA) Severe NPDR without maculopathy Refer to Ophthalmologist
More than just microaneurysms but less than Any maculopathy
Moderate NPDR
severe NPDR Proliferative DR
Arrange for fundus photography/
ophthalmoscopy Refer urgently to Ophthalmologist
Any of the following: Advanced Diabetic Eye Disease (ADED)
No DR to Mild NPDR
1. More than 20 intraretinal haemorrhages Every 3 months
Perform fundus photography/ in Pregnant Women
complete fundus assessment in each of 4 quadrants
Moderate NPDR or Worse
Severe NPDR Refer to Ophthalmologist
2. Definite venous beading in 2 or more quadrants in Pregnant Women
Yes Ability to view/
grade fundus
No
3. Prominent intraretinal microvascular Criteria for Urgent Referral to Opthamologist
abnormalities in 1 or more quadrants
AND no signs of proliferative retinopathy Urgency of referral Ocular features
• Sudden severe visual loss
One of the following:
Emergency (same day referral) • Symptoms or signs of acute
• No Diabetic Retinopathy (DR)
• Mild Non-Proliferative Diabetic • Severe NPDR or worse Proliferative DR (PDR) 1. Neovascularisation retinal detachment
Retinopathy (NPDR) without • Any diabetic maculopathy Refer Ophthalmologist • Presence of retinal new vessels
diabetic maculopathy regardless of DR stages
• Moderate NPDR without
2. Vitreous/preretinal haemorrhage • Preretinal haemorrhage
diabetic maculopathy Within 1 week
• Vitreous haemorrhage
One of the following:
• Rubeosis iridis
Follow-up 1. Formation of fibrovascular tissue proliferation • Unexplained drop in visual acuity
• Any form of maculopathy
Advanced Diabetic Eye 2. Traction retinal detachment due to formation of Within 4 weeks
• Severe NPDR
Disease (ADED) posterior vitreous detachment • Worsening retinopathy
Recommendation
• Screening for diabetic retinopathy should be done in all patients with 3. Dragging of retinal/distortion
diabetes mellitus. Target Level of Modifiable Risk Factors in Adults
4. Rhegmatogenous retinal detachment
Glycemic control Target LEVEL
Recommendation
Macula Oedema Findings on Ophthalmoscopy 1) Fasting Blood Glucose 4.4 - 6.1 mmol/L
• First screening for diabetic retinopathy (DR) should be done at:
2) Non-Fasting Blood Glucose 4.4 - 8.0 mmol/L
o Adults type 1 diabetes mellitus (T1DM) - up to 3 years after diagnosis Absent No retinal thickening or hard exudates in posterior pole 3) HbA1c <6.5%
o Adults type 2 diabetes mellitus (T2DM) - at time of diagnosis
o Pregnant women with Present • Mild – some retinal thickening or hard exudates Lipid Target LEVEL
i. Pre-existing diabetes mellitus (DM) - prior to planned pregnancy in posterior pole but distant from the macula 1) Triglicerides <1.7 mmol/L
ii. Gestational DM (GDM) diagnosed in the first trimester 2) LDL-cholesterol <2.6 mmol/L
• Moderate – retinal thickening or hard exudates 3) HDL-cholesterol >1.1 mmol/L
- at the time of diagnosis. Otherwise not required.
approaching the centre of the macula but not Body Mass Index <23 kg/m2
o Children T1DM involving the centre
i. At age 9 years with 5 years of DM duration Blood pressure Target LEVEL
ii. At age 11 years with 2 years of DM duration • Severe – retinal thickening or hard exudates 1) Normal Renal Function 130/80 mmHg
o Children T2DM - at time of diagnosis involving the centre of the macula 2) Renal Impairment / 125/75 mmHg
micro- or macroalbuminuria