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New guidelines for diabetic retinopathy

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Health-care organisations in Australia are increasingly advocating a multidisciplinary approach to diabetes, in which optometrists are expected to play a key role in early diagnosis, monitoring and patient awareness.

In April 2014, the Royal Australian College of General Practitioners updated its General Practice Management of Type 2 Diabetes Guidelines. Optometry Australia’s revised diabetes guidelines were released in June 2014.

Optometry Australia had established its own working group* to review its diabetic retinopathy clinical guidelines and the 12-month review process concluded in May 2014.

The National Health & Medical Research Council (NHMRC) last revised its Clinical Practice Guidelines for the Management of Diabetic Retinopathy in 2008. Developed by the Australian Diabetes Society’s expert panel and citing literature only up to 2006, the NHMRC guidelines were soon outdated.

While drawing heavily on the NHMRC’s guidelines, Optometry Australia’s guidelines for the Examination and Management of Patients with Diabetes recognise technologies such as digital retinal imaging and OCTs, as well as the new treatment modalities for diabetic macular oedema, particularly anti-VEGF therapy.

Tacitly acknowledging the changing role optometry plays in the diagnosis and monitoring of mild to moderate non-proliferative diabetic retinopathy, the revised guidelines advocate the use of the International Clinical Diabetic Retinopathy and Diabetic Macular Oedema Disease Severity scale (Table 1). The scale simplifies classification of diabetic retinopathy and is seen as a more clinically useful measure than the Wisconsin scale it replaces.

OL-024-DR-Guidelines-Table-1
Table 1. International Clinical Diabetic Retinopathy and Diabetic Macular
Oedema Disease Severity Scale and recommended referral patterns

Multidisciplinary approach

Optometry Australia’s new guidelines offer optometrists a concise resource to facilitate consultations and to encourage optimum health outcomes for the 1.6 million Australians diagnosed with diabetes mellitus.

The principal optometrist at the Centre for Eye Health, Paula Katalinic, was a member of the working group that contributed to the revised guidelines. Ms Katalinic, who completed a three-year tenure at the renowned Joslin Diabetes Center in Boston, says that one of the main points the working group wanted to stress was the important role of optometry in a multidisciplinary diabetes team.

‘Whether or not a person with diabetes has signs of diabetic retinopathy may influence the clinical decision-making of GPs and endocrinologists in terms of the optimal level of glycaemic control for that particular patient, and treatment of other risk factors for diabetic retinopathy such as blood pressure and cholesterol,’ Ms Katalinic said. ‘It’s important that the results of the eye exam be communicated to the patient’s GP or endocrinologist following every visit.

‘Understanding that the level of diabetic retinopathy is predictive of the rate of progression to vision-threatening disease is important. It will minimise unnecessary referrals to ophthalmologists for those who could be safely monitored by optometrists, and allow more appropriately-timed referrals,’ Ms Katalinic said. ‘For instance, a person with mild non-proliferative diabetic retinopathy has only a minimal risk of progressing to significant levels of retinopathy in 12 months and can be safely monitored by the optometrist if the optometrist feels they have the clinical skills and knowledge to do so.’

OL-024-DR-Guidelines-Table-2

Table 2 lists recommended examination procedures for examining
patients with diabetes.

Beyond the vitally important functions of diagnosis, monitoring and referral, optometrists can play a key role in educating diabetic patients and encouraging adherence to a diabetes care plan by turning the discussions about their OCT scans and retinal images into opportunities to educate. For patients with diabetes, seeing the early visible clinical manifestations of diabetic retinopathy reinforces the importance of blood glucose control and regular eye examinations.

Paula Katalinic suggests saving a few de-identified images of late-stage diabetic retinopathy to show to patients so they can understand that the better care they take of themselves, the lower their risk of vision loss due to diabetes will be. ‘It really is true that a picture is worth a thousand words when it comes to the education of a person with diabetes,’ she said.

‘It’s important for optometrists to build a professional relationship with their local ophthalmologist and GP,’ Ms Katalinic said. ‘It is worth letting them know that you want to work with them to best manage the patient’s visual needs. This, in turn, will lead to future referrals of other patients.

‘Practising to the standard of care, dilating all patients with diabetes, accurately grading the level of diabetic retinopathy and macular oedema, and referring in a timely manner will build respect and are likely to enhance the relationship with your fellow health-care providers,’ she said.

Following the TGA’s approval of fenofibrate as an indication to slow the progression of existing diabetic retinopathy in people with type 2 diabetes, timely referral to GPs has become critical. As the new guidelines explicitly spell out, everyone with diabetes is at risk of developing diabetic retinopathy, and thorough eye examinations are important for early diagnosis and treatment to prevent vision loss. As never before, optometrists are ideally placed to detect previously undiagnosed cases of diabetic retinopathy.

By familiarising yourself with the risk factors for developing diabetic retinopathy, the severity scales and recommended referral patterns, you can actively participate in the kind of  multidisciplinary diabetes team that is necessary to ensure optimal patient care.

Download the full Clinical guidelines for examining and managing patients with diabetes

*  The working group participants were: Giuliana Baggoley (convener until December 2013); Simon Hanna, Optometry Australia clinical policy adviser (convener from February 2014); Graham Fist, optometrist; Eve Hsing, optometrist; Paula Katalinic, Principal Optometrist, Centre for Eye Health and professional services manager, Optometry NSW/ACT; Josephine Li, optometrist, Australian College of Optometry; Lisa Penrose, optometrist and observer to the board of Optometry Queensland & Northern Territory; Roman Serebrianik, Lead Optometrist Primary Care, Australian College of Optometry.



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