Perspectives in Disease Prevention and Health Promotion
Guidelines for Diabetic Eye Disease Control -- Kentucky
Diabetic eye disease is the leading cause of new cases of
blindness in the United States in adults 75 years of age.
Furthermore, people with diabetes are at increased risk for visual
loss due to diabetic retinopathy, glaucoma, and cataracts. Early
identification and treatment of diabetic retinopathy can reduce
severe
visual loss by 60%. Since detection of proliferative eye disease
is
subtle, it is best performed by persons specially trained in eye
disease. However, since patients with retinopathy are usually
asymptomatic at the most treatable stage of their disease, they may
not seek an examination at that time. For these reasons,
policymakers
in the state of Kentucky felt that specific guidelines for diabetic
eye disease management were necessary. A panel of national and
state
experts addressed this issue at a meeting sponsored by the diabetes
coordinating center of the World Health Organization in Kentucky.
Guidelines for Diabetic Eye Disease Control
Eye care for the patient with diabetes requires a partnership
between the primary physician, the eye-care specialist, and the
patient. The primary care physician not only plays a fundamental
role
in medical management of the patient, including control of blood
glucose and blood pressure, but also assumes responsibility for
patient education and coordination of care. Consequently, the
primary
care physician should be aware of recommendations for ophthalmic
care. These guidelines are intended to familiarize all involved
health professionals with these needs.
All patients should be informed (a) that sight-threatening eye
disease is a common complication of diabetes mellitus and can
often be present even with good vision and (b) that early
detection and appropriate treatment of diabetic eye disease
greatly reduce the risk of visual loss.
Patients with diabetes mellitus should have their first
complete
eye examination after 5 years duration of diabetes if they are
between 10 and 30 years of age or at the time of diagnosis of
diabetes if they are over 30 years of age.
This initial eye examination should include a history of visual
symptoms, a measurement of visual acuity and intraocular
pressure,
and an ophthalmoscopic examination through dilated pupils.
After the initial eye examination, persons with diabetes
mellitus
should receive the above ophthalmic examinations annually
unless
more or less frequent examinations are indicated by the
presence
or absence of abnormalities.
It is desirable that any woman who has insulin-dependent
diabetes
mellitus and who is planning (considering) pregnancy within 12
months should be under the care of an ophthalmologist.
A woman with established diabetes mellitus (diagnosed prior to
conception) who becomes pregnant should be examined for
retinopathy by an ophthalmologist in the first trimester and
thereafter at the discretion of the ophthalmologist.
Patients should be referred to an ophthalmologist promptly for
unexplained visual symptoms, reduced corrected visual acuity,
increased intraocular pressure, any retinal abnormalities, or
any
other ocular pathology that threatens vision.
All patients should be under the care of a retinal specialist
or
other ophthalmologist experienced in the management of diabetic
retinopathy when the following conditions are suspected or have
been positively identified:
Preproliferative retinopathy (multiple cotton-wool spots,
multiple
intraretinal hemorrhages, intraretinal microvascular abnormalities,
or
venous beading).
Proliferative retinopathy (retinal neovascularization,
preretinal
or vitreous hemorrhage, fibrosis, or traction retinal detachment).
Macular edema (hard lipid exudates and/or retinal thickening
inside the temporalvascular arcades).
9. Laser photocoagulation therapy is effective in reducing the
risk
of visual loss in patients with high-risk proliferative
retinopathy and clinically significant macular edema.
Vitrectomy
can restore vision in certain patients with recent traction
retinal detachment and/or vitreous hemorrhage. Laser therapy
and
vitrectomy should be performed by a retinal specialist or other
ophthalmologist experienced in these procedures.
10. Patients with functionally decreased visual acuity should
undergo
low vision evaluation and rehabilitation.
These guidelines are currently being considered for approval by
state and national groups. A task force is developing an
implementation plan for Kentucky.
Reported by P Allweiss, MD, S Leichter, MD, Kentucky Diabetes
Foundation, W Wood, MD, Lexington, C Hernandez, MD, MPH, Dept of
Health Svcs, Kentucky Cabinet for Human Resources; Div of Diabetes
Control, Center for Preventive Svcs, CDC.
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