German Diabetes Associaton: Clinical Practice Guidelines

387

Authors

H. P. Hammes1, K. D. Lemmen2, B. Bertram3

Affiliations

1 2 3

V. Med. Klinik, Universitätsklinikum Mannheim, Mannheim St. Martinus-Krankenhaus, Augenklinik, Düsseldorf Augenärztl. Praxis, Aachen

Epidemiology

Risk Factors

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Diabetic retinopathy is a frequent microvascular complication of diabetes mellitus.

Patients with Type 1 Diabetes !

▶ Retinopathy is rare in children before puberty ▶ Up to 85 % of patients with diabetes for 25 years or more years may develop retinopathy

▶ Diabetic maculopathy is present in 15 % of patients with diabetes for more than 15 years

Patients with Type 2 Diabetes !

▶ Up to one third of patients are diagnosed as hav▶ Last update 3/2014

Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1366292 Exp Clin Endocrinol Diabetes 2014; 122: 387–390 © J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York · ISSN 0947-7349 Correspondence Prof. Dr. med. H. P. Hammes Sektionsleitung Endokrinologie V. Medizinische Klinik Universitätsklinikum Mannheim Theodor Kutzer-Ufer 1–3 68177 Mannheim Tel.: 06 21/3 83 26 63 Fax: 06 21/3 83 38 04 [email protected] ma.uni-heidelberg.de



ing mild retinopathy when diabetes is detected Nearly 80 % of patients develop retinopathy after 15 to 20 years Diabetic maculopathy can occur in nearly 25 % of patients

▶ hyperglycaemia ▶ arterial hypertension ▶ diabetes duration ▶ hormonal changes (pregnancy, puberty) ▶ smoking ▶ concomitant nephropathy Early Worsening of Diabetic Retinopathy !

Early worsening (euglycaemic re-entry) of retinopathy affects patients with type 1 diabetes. It is rare (< 5 % of the patients), occurs primarily during the first 12 months of metabolic improvement, and is more frequent in patients with diabetes duration > 10 years and long term poor glycaemic control (HbA1c > 10 %). It cannot be prevented by gradual improvement of HbA1c. The positive effect of improved glycaemic levels outweighs early worsening.

Diagnostic Work-Up Symptoms

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!

Check the following items: ▶ visual acuity ▶ lens and vitreous ▶ intraocular pressure (in cases of severe nonproliferative or proliferative retinopathy or advanced eye disease), ▶ ocular fundus using binocular biomicroscopic funduscopy (in mydriasis) The results should be documented using standard " Fig. 1). examination procedures (●

Diabetic retinopathy and maculopathy usually develop and progress without symptoms. Fundus screening is mandatory, since only advanced stages cause symptoms. Signs and symptoms that suggest the development of retinopathy are: ▶ sudden drop of visual acuity ▶ non-correctable drop of visual acuity If the macula is affected: ▶ impaired vision ▶ impaired colour vision ▶ blurred vision ▶ “floaters” seen in front of the eye; these are caused by vitreous haemorrhages or tractive retinal detachments.

Treatment Objectives !

Prevention of visual loss and blindness through interdisciplinary cooperation by:

Hammes HP et al. Diabetic Retinopathy and … Exp Clin Endocrinol Diabetes 2014; 122: 387–390

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Diabetic Retinopathy and Maculopathy

German Diabetes Associaton: Clinical Practice Guidelines

▶ near normoglycaemia as safely as possible ▶ blood pressure normalization (< 140/80 mm Hg) ▶ ophthalmological treatment (laser/IVOM). Examination Schedule as a Rule !

The following apply in principle: ▶ Retinopathy absent – Examination by a retina specialist once per year ▶ If retinopathy is present, examination at intervals as specified by the retina specialist.

Exceptions !

▶ Children below the age of 11 do not need fundus inspection until they have had diabetes for 5 years or more

▶ Pregnant women with type 1 diabetes must be examined at diagnosis with close follow-up throughout pregnancy

▶ Type 2 diabetes: shortly after diagnosis of diabetes ▶ Patients at high risk of early worsening (T1 Diabetes) must be monitored by a retina specialist before ICT is established.

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388

Hammes HP et al. Diabetic Retinopathy and … Exp Clin Endocrinol Diabetes 2014; 122: 387–390

German Diabetes Associaton: Clinical Practice Guidelines

389

Annex

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!

Fig. 1

Standardised Ophthalmological Examination Sheet.

Hammes HP et al. Diabetic Retinopathy and … Exp Clin Endocrinol Diabetes 2014; 122: 387–390

German Diabetes Associaton: Clinical Practice Guidelines

Table 1

Stages, ophthalmological finding and therapy.

Stage

Ophthalmological finding

Ophthalmological therapy

1.1 non-proliferative diabetic retinopathy mild level

microaneurysms

no laser coagulation

moderate level

additionally, isolated intraregional hemorrhages and/or some venous beading

no laser coagulation

severe level

“4-2-1-rule”: > 20 isolated microaneurysms and intraretinal hemorrhages in 4 quadrants or venous beading in 2 quadrants or intraretinal micro vascular abnormalities (IRMA) in 1 quadrant

laser coagulation only for patients at risk

neovascularization of the disk, neovascularization elsewhere

laser coagulation

vitreous hemorrhage, retinal detachment

laser coagulation if possible; alternative vitrectomy

focal areas of oedema, hard exudates or intraretinal haemorrhages at the posterior pole

no laser coagulation

like 2.1, but parafoveal vision threatening form = clinically significant macular oedema

targeted laser coagulation

2.2 diffuse macular oedema

extensive oedema of the macula and beyond, with hard exudates and intraregional haemorrhages

grid laser photocoagulation − IVOM if center isinvolved

2.3 ischaemic maculopathy

diagnosis using fluorescence angiography: progressive occlusion of the perifoveal capillary network

no therapy available

2. diabetic Maculopathy

Family doctor

2.1 focal macular oedema

Newly diagnosed type 2 diabetes

Established type 2 diabetes

Acute vision loss

Summary of findings / referral to an eye doctor for initial examination

Summary of findings / referral to an eye doctor (at least once a year)

Immediate referral to an eye doctor

Eye doctor

Ophthalmological examination according to guideline No retinal disease present

Newly diagnosed retinopathy/maculopathy

Follow up in one year

if necessary: treatment follow-up specified

Follow-up and management of the diabetes therapy

When disease progresses: reevaltion of the risk and treatment

Long term follow-up by family doctor

Hammes HP et al. Diabetic Retinopathy and … Exp Clin Endocrinol Diabetes 2014; 122: 387–390

Fig. 2 Procedure for type 2 diabetes pursuant to the National Disease Management Guideline “Diabetic Retinopathy and Maculopathy”.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

1.2 proliferative diabetic retinopathy

Family doctor

390

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