Evidence-Based Clinical Practice Guideline

Eye Care of the Patient With

DIABETES
MELLITUS

optometry: The primary eye care profession

he American Optometric Association represents approximately 36,000 doctors of optometry, optometry

students and paraoptometric assistants and technicians. Optometrists serve individuals in nearly 6,500
communities across the country, and in 3,500 of those communities, they are the only eye doctors.
Doctors of optometry provide two-thirds of all primary eye care in the United States.
Doctors of optometry are on the frontline of eye and vision care. They examine, diagnose, treat and manage
diseases and disorders of the eye. In addition to providing eye and vision care, optometrists play a major
role in an individuals overall health and well-being by detecting systemic diseases such as diabetes and
hypertension.
The mission of the profession of optometry is to fulfill the vision and eye care needs of the public through
clinical care, research and education, all of which enhance the quality of life.

Disclosure Statement
This Clinical Practice Guideline was funded by the American Optometric Association (AOA) without financial
support from any commercial sources. All Committee, Guideline Development Group, and other guideline
participants provided full written disclosure of conflicts of interest prior to each meeting and prior to voting
on the strength of evidence or clinical recommendations contained within.
Disclaimer
Recommendations made in this guideline do not represent a standard of care. Instead, the recommendations
are intended to assist the clinician in the decision-making process. Patient care and treatment should always
be based on a clinicians independent professional judgment, given the individuals circumstances, state laws
and regulations.
The information in this guideline is current as of the date of publication.

Evidence-Based Clinical Practice Guideline

EYE CARE OF THE PATIENt with

DIABETES MELLITUS
Developed by the AOA Evidence-Based Optometry Guideline Development Group.
Approved by the AOA Board of Trustees, February 7, 2014
American Optometric Association 1993, 1998, 2002, 2009, 2014
243 N. Lindbergh Blvd., St. Louis, MO 63141-7881

Table of Contents

A. What is the Evidence-Based Process?........... 6

B. Non-retinal Ocular Complications.................... 21

1. Classification and Signs of Non-retinal Ocular
Complications................................................ 21
a. Visual Function........................................... 21
b. Eye Movement Anomalies......................... 22
c. Pupillary Reflexes....................................... 22
d. Conjunctiva................................................. 22
e. Tear Film.................................................... 22
f. Cornea......................................................... 23
g. Iris............................................................... 23
h. Lens............................................................ 23
i. Vitreous........................................................ 24
j. Optic Disc................................................... 24

B. How to Use This Guideline............................... 8

I. INTRODUCTION................................................. 9
A. Guideline Objectives....................................... 10
II. CLASSIFICATION, EPIDEMIOLOGY AND RISK
FACTORS FOR DIABETES MELLITUS............... 10
A. Disease Definition........................................... 10
B. Description and Classification of
Diabetes Mellitus................................................. 10
1. Classification.................................................. 10
a. Type 1 Diabetes Mellitus........................ 11
b. Type 2 Diabetes Mellitus........................ 11
c. Pre-Diabetes............................................ 11
d. Gestational Diabetes Mellitus.................. 12
e. Other Specific Types of Diabetes.......... 12
2. Background................................................... 12
a. Natural History of Diabetes Mellitus....... 12
b. Diagnostic Criteria................................... 13
C. Epidemiology of Diabetes Mellitus................ 14
1. Prevalence and Incidence.......................... 14
a. Type 1 Diabetes Mellitus........................ 14
b. Type 2 Diabetes Mellitus........................ 14
c. Pre-Diabetes............................................ 15
D. Risk Factors for Diabetes Mellitus................ 15
1. Type 1 Diabetes Mellitus........................... 15
2. Type 2 Diabetes Mellitus........................... 15
3. Screening for Diabetes Mellitus................. 15
4. Early Detection and Prevention................. 16

III. OCULAR COMPLICATIONS OF DIABETES
MELLITUS............................................................ 16

IV. DIAGNOSIS OF OCULAR COMPLICATIONS OF

DIABETES MELLITUS.............................................25
A. Individuals with Undiagnosed Diabetes Mellitus...25
1. Patient History...................................................25
2. Diabetes Risk Assessment................................25
3. Ocular Examination............................................26
B. Individuals with Diagnosed Diabetes Mellitus.26
1. Patient History...................................................26
2. Ocular Examination............................................27
3. Supplemental Testing........................................28
C. Ocular Examination Schedule...........................30
1. Persons with Diabetes Mellitus.........................30
2. Persons with Non-retinal Ocular Complications
of Diabetes Mellitus...........................................31
3. Persons with Retinal Complications of Diabetes
Mellitus...............................................................31
4. Clinical Recordkeeping......................................33

V. TREATMENT AND MANAGEMENT....................33
A. Management of Ocular Complications of
Diabetes Mellitus.....................................................33
1. Basis for Treatment...........................................33
a. Persons with Undiagnosed Diabetes
Mellitus........................................................33
b. Persons with Non-retinal Ocular
Complications..............................................33
c. Persons with Retinal Complications...........36
2. Treatment of Retinal Complications..................37
a. Laser Photocoagulation...............................37

A. Diabetic Retinal Disease................................ 16

1. Epidemiology of Diabetic Retinal Disease and
Vision Loss.................................................... 17
2. Classification and Signs of Diabetic
Retinopathy.................................................... 18
a. Non-proliferative Diabetic Retinopathy.... 19
b. Proliferative Diabetic Retinopathy........... 19
c. Diabetic Macular Edema......................... 21

VIII. METHODOLOGY FOR GUIDELINE

DEVELOPMENT.........................................................81

b. Vitrectomy..................................................39
c. Intraocular Steroids....................................40
d. Vascular Endothelial Growth Factor
Inhibitors.....................................................40
3. Telehealth Programs.........................................42
4. Patient Education.............................................42
5. Prognosis and Follow-Up.................................44
B. Management of Systemic Complications and
Comorbidities of Diabetes Mellitus.................44
1. Glycemic Control..............................................44
2. Blood Pressure Control....................................46
3. Lipid-Lowering Treatment.................................46
4. Cardiovascular Risk Reduction........................47
5. Physical Exercise..............................................47
6. Weight Management........................................47
7. Treatment Modalities........................................48
C. Management of Persons with
Visual Impairment................................................51
D. Summary.............................................................52

IX. EVIDENCE-BASED OPTOMETRY GUIDELINE

DEVELOPMENT GROUP...........................................83

VI. REFERENCES....................................................53
VII. APPENDIX.........................................................67
a. Appendix Figure 1: Optometric Management of
the Person with Undiagnosed Diabetes Mellitus:
A Flowchart........................................................ 67
b. Appendix Figure 2: Optometric Management of
the Person with Diagnosed Diabetes Mellitus:
A Flowchart........................................................ 68
c. Appendix Figure 3: Early Treatment Diabetic
Retinopathy Study Grading System Standard
Photographs........................................................ 69
d. Appendix Table 1: Comparison of the Early
Treatment Diabetic Retinopathy Study and
International Clinical Diabetic Retinopathy and
Macular Edema Severity Scale.......................... 70
e. Appendix Table 2: Effects of Systemic
Medications on the Onset and Progression
of Diabetic Retinopathy...................................... 72
f. Abbreviations of Commonly Used Terms.......... 74
a.
g. Glossary.............................................................. 76
h. Summary Listing of Action Statements............. 78

EVIDENCE-BASED CLINICAL
GUIDELINES

relationships between alternative care options

and health outcomes.
Provide a grading of both the strength of the
quality of evidence and the strength of the
clinical recommendation.

A. What is the Evidence-Based Process?

s a result of the Medicare Improvement for

Patients and Providers Act of 2008, Congress
commissioned the U.S. Secretary of Health and
Human Services to create a public-private program
to develop and promote a common set of standards
for the development of clinical practice guidelines
(CPGs). These standards address the structure,
process, reporting, and final products of systematic
reviews of comparative effectiveness research and
evidence-based clinical practice guidelines.

Be revised as appropriate when new evidence

warrants modifications of recommendations.
Based on the IOM reports, the American Optometric
Association (AOA) Evidence-Based Optometry (EBO)
Committee developed a 14-step process to meet the
new evidence-based recommendations for trustworthy
guidelines.

The Institute of Medicine (IOM), through the Agency

for Healthcare Research and Quality (AHRQ),
issued two reports in March 2011: Clinical Practice
Guidelines We Can Trust and Finding What Works in
Health Care: Standards for Systematic Reviews.
1

In Clinical Practice Guidelines We Can Trust, the

IOM redefined CPGs as follows:
Clinical Practice Guidelines are statements that
include recommendations intended to optimize
patient care that are informed by a systematic
review of the evidence and an assessment of the
benefits and harms of alternative care options.
The report states that to be trustworthy, guidelines
should:
Be based on a systematic review of existing
evidence.
Be developed by a knowledgeable,
multidisciplinary panel of experts and key
stakeholders.
Consider important patient subgroups and
preferences as appropriate.
Be based on a transparent process that
minimizes conflicts of interest and biases.
Provide a clear explanation of the logical

Revised 1-24-2014

AOAs 14 Steps to Evidence-Based Clinical Practice Guideline Development

1.

Guideline Development Group: Select a multidisciplinary panel of experts, including patient

and public representatives, for Guideline Development Group (GDG).

2.

Transparency and COI: Manage conflict of interest (COI).

3.

Clinical Questions**: Explore and define all clinical questions through a Question Formulation
Meeting and define search criteria (GDG).

4.

Search for Evidence: Send clinical questions for query (outside researchers) and provide all
papers to the Guideline Development Reading Group (GDRG). There should be no inclusion
of Systematic Review (SR) writers in the Guideline Development Group (No intersection of
GDG with SR writers; not applicable to AOA at this time).

5.

Grade Evidence and Clinical Recommendations: Read and grade papers (2 GDRG readers
per paper, randomly selected) according to pre-designed evidence quality values. Make
clinical recommendation(s) from each paper and grade the strength of each (GDRG).

6.

Articulate Clinical Recommendations**: Review all clinical recommendations and articulate

each for inclusion in the guideline during an Articulation of Recommendations meeting and
document identified gaps in medical research (GDRG).

7.

Write Draft: Send to writer for development of draft 1.

8.

Draft Review and Edits**: Read draft 1, discuss and edit (GDG).

9.

Rewrite/Final Drafts: Send to writer for writing/revisions for draft 2, then final reading /
changes/rewrites as necessary.

10.

Approval for Peer Review: Send to the AOA Board of Trustees for approval to post for peer
and public review. Post on the AOA website, announce the review period, and solicit
comments.

11.

Final Document Produced: Review and revise final document (include peer review comments
or identify issues for review when preparing next edition).

12.

Final Approval and Legal Review: Send to the AOA Board of Trustees and AOA Legal
Counsel for approval (same management of COI).

13.

Post Guideline: Submit to the National Guideline Clearinghouse and website for public use,
accompanied by AOA written process and documents. Post to the AOA website.

14.

Schedule Reviews: Review all previously identified gaps in medical research and any new
evidence, and revise guideline every 2 to 5 years.
** Denotes face-to-face meeting

B. How to Use This Guideline

he following table provides the grading system used in this guideline for rating
evidence-based clinical statements. Grades are provided for both strength of the
evidence and clinical recommendations.

Key to Strength of Evidence and

Clinical Recommendation Grading

GRADE STRENGTH OF EVIDENCE

Data derived from well-designed, multiple randomized clinical trials, meta-analyses (Systematic
Review) or diagnostic studies of relevant populations.
Randomized Control Studies (RCTs), Systematic Reviews with meta-analysis when available,
Diagnostic Studies.

RCTs or diagnostic studies with minor limitations; overwhelmingly consistent evidence from
observational studies.
Weaker RCTs (weak design but multiple studies confirm).
Cohort Study (this may include retrospective and prospective studies).

Studies of strong design, but with substantial uncertainty about conclusions, or serious doubts about
generalization, bias, research design, or sample size; or retrospective or prospective studies with
small sample size.

Expert opinion, case reports, reasoning from principles.

No evidence is available that directly supports or refutes the conclusion.
Cross-sectional studies, case series/ case reports, opinion or principle reasoning.

GRADE CLINICAL RECOMMENDATION

Clinicians should follow this recommendation unless clear and compelling rationale for an alternative
approach is present. There is a clinically important outcome and the study population is
representative of the focus population in the recommendation. The quality of evidence may not be
excellent, but there is clear reason to make a recommendation.

Clinicians should generally follow this recommendation, but should remain alert for new information.
There is a clinically important outcome but it may be a validated surrogate outcome or endpoint.
The benefits exceed the harm or vice versa, but the quality of evidence is not as strong.

Clinicians should be aware of this recommendation, and remain alert for new information. The
evidence quality that exists is suspect or the studies are not that well-designed; well conducted
studies have demonstrated little clear advantage of one approach versus another.

Clinicians should be aware of this recommendation. The outcome is an invalid surrogate for a
clinically important population, or the applicability of the study is irrelevant. There is both a lack of
pertinent evidence and an unclear balance between benefit and harm.

As you navigate through the guideline, note the following:

Grades are displayed with the evidence strength listed first, followed by the strength of the clinical
recommendation. A statement with a strength of evidence of B and a clinical recommendation of A is
shown as B/A.
Evidence-based Clinician Action Statements will be highlighted in an Action box, with the strength of
evidence and clinical recommendation grades listed.
ACTION: Individuals with diabetic macular edema (DME), but without clinically significant macular edema
(CSME), should be re-examined at 4- to 6-month intervals. Once CSME develops, treatment with
178
focal laser photocoagulation or intravitreal anti-VEGF injection is indicated. [Evidence Strength: A,
Recommendation: A]
Consensus-based Clinician Action Statements, based on consensus by the Guideline Development
Reading Group (GDRG), will be highlighted in an Action box, without any strength of evidence or clinical
recommendation grade listed.
ACTION: Women with pre-existing diabetes who are planning pregnancy or who become pregnant should
have a comprehensive eye examination prior to a planned pregnancy or during the first trimester, with
follow-up during each trimester of pregnancy.

I. INTRODUCTION

shown to decrease the risk of the development of

3
diabetic retinopathy by as much as 76 percent.
However, as many as 40 percent of people with
4
diabetes dont know they have the disease. For
some, signs of diabetes found during an eye
examination may be the initial indication of the
5
presence of the disease.

ype 2 diabetes is the most prevalent form of

diabetes mellitus and often goes undiagnosed
for many years because high blood glucose
levels develop gradually and initially are often not
severe enough for a person to notice any of the
symptoms of diabetes. However, during this time,
individuals are at risk of developing microvascular
and macrovascular complications of diabetes,
including visual impairment and blindness,
hypertension, renal failure, heart disease, and stroke.

Optometrists are often the first health care

practitioners to examine persons with undiagnosed
diabetes mellitus or ocular manifestations of diabetes.
This Evidence-Based Clinical Practice Guideline
on Eye Care of the Patient with Diabetes Mellitus
provides doctors of optometry with examination and
management recommendations designed to preserve
vision and reduce the risk of vision loss in persons
with diabetes, through timely diagnosis, appropriate
management and referral.

Diabetic retinopathy, the most common microvascular

complication of diabetes, is the leading cause of new
cases of blindness and low vision among Americans
20 to 74 years of age. Diabetic retinopathy accounts
for approximately 12 percent of all new cases of
2
blindness each year.
Intensive treatment to maintain blood glucose
concentrations close to the normal range has been

A. Guideline Objectives
This Guideline will assist optometrists in achieving the
following objectives:
Identification of individuals at risk for diabetes
Identification of individuals with undiagnosed
diabetes mellitus
Identification of individuals at risk of vision loss
from diabetes
Preservation of vision by reducing the risk of
vision loss in persons with diabetes through
timely diagnosis, intervention, determination
of need for future evaluation, and appropriate
referral
Improvement in the quality of care rendered to
persons with diabetes
Education of individuals and health care
practitioners regarding the ocular complications
of diabetes
Dissemination of information and education of
individuals on the benefits of vision rehabilitation
Provision of vision rehabilitation services or
referral for care of persons with vision loss
from diabetes

II. CLASSIFICATION, EPIDEMIOLOGY

AND RISK FACTORS FOR DIABETES
MELLITUS
A. Disease Definition

iabetes mellitus is a group of metabolic

diseases characterized by hyperglycemia
resulting from defects of insulin secretion
and/or increased cellular resistance to insulin. It is
a chronic disease with long-term macrovascular
and microvascular complications, including diabetic
6
nephropathy, neuropathy, and retinopathy.

Diabetes is a significant, costly, and potentially

preventable public health problem. It is the seventh

leading cause of death in the United States and
the direct and indirect cost of care for persons with
7
diabetes exceeds $245 billion annually. An estimated
25.8 million Americans (8.3 percent of the population)
have diabetes. In 2010, about 1.9 million new cases
of diabetes were diagnosed in people aged 20 years
8
or older in the United States. If the current trend
continues, one in three adults in the United States
9
will have diabetes by 2050.
Because it can lead to blindness, diabetic retinopathy
is the most significant vision threatening complication
of diabetes. While advances in the management of
diabetes and diabetic retinopathy have reduced the
10
risk of vision loss and blindness, as many as 1/3
to 1/2 of persons with diabetes dont receive an
11,12
annual eye examination.
In addition, about 20
to 40 percent of individuals with type 2 diabetes
have retinopathy at the time of first diagnosis of
13,14
diabetes.
These findings are particularly important as the
15-27
Diabetic Retinopathy Study (DRS),
the Early
2850
Treatment Diabetic Retinopathy Study (ETDRS),
51the Diabetic Retinopathy Vitrectomy Study (DRVS),
55
the United Kingdom Prospective Diabetes Study
56-59
(UKPDS),
the Diabetes Control and Complications
Trial/Epidemiology of Diabetes Interventions and
3,60-63
Complications (DCCT/EDIC) studies,
and the
Diabetic Retinopathy Clinical Research Network
64-71
(DRCR.net)
provide evidence-based care
interventions that rely on early referral for eye care
with prompt and appropriate intervention to lessen
the risk for and the severity of vision loss related
to diabetes. Timely diagnosis, intensive diabetes
treatment, and consistent, long-term follow-up
evaluations for persons with diabetes are essential
for effective care, which can preserve vision and
substantially lower the risk of vision loss.

B. Description and Classification

of Diabetes Mellitus
1. Classification
The definitions and categories of diabetes used

10

in this document are based on the most recent

classifications reported by the American Diabetes
6
Association (ADA).

the body does not produce enough insulin (relative

insulin deficiency) or cannot use the insulin it
makes effectively (insulin resistance). It is the
most common form of diabetes worldwide and its
prevalence is increasing.

a. Type 1 Diabetes Mellitus

Type 1 diabetes (formerly called insulin-dependent
or juvenile diabetes) occurs when the bodys
immune system attacks and destroys insulinproducing beta-cells in the pancreas. It accounts
for approximately 5 to 10 percent of individuals
8
with diabetes in the United States. The primary
characteristic of type 1 diabetes is absolute
dependence on exogenous insulin to prevent
profound hyperglycemia and ketoacidosis.

Type 2 diabetes accounts for 90 to 95 percent

8
of diabetes cases. In contrast to type 1 diabetes,
with this form of the condition, autoimmune
destruction of beta-cells does not occur.
Type 2 diabetes develops more frequently in
adults than in children. However, the prevalence of
type 2 diabetes in children is increasing, especially
in high-risk ethnic groups, such as American
Indians, Hispanic Americans, African Americans,
Alaska Natives, Asian Americans, Native Hawaiians
and Other Pacific Islanders. Most of these children
are between 10 and 19 years old, have infrequent
or mild diabetic ketoacidosis, are obese and have
72
a strong family history of diabetes.

Type 1 diabetes, although generally diagnosed

in children and young adults, can occur at any
age. It may be caused by genetic, environmental,
or other factors, and currently there is no known
way to prevent it.
There are two forms of type 1 diabetes, both
of which are characterized by destruction and/
or loss of secretory function by insulin producing
pancreatic beta-cells. One form is an immunemediated disease with autoimmune markers such
as islet cell antibodies (ICAs), insulin autoantibodies
(IAAs), and autoantibodies to glutamic acid
decarboxylase (GAD65). As many as 85 to 90
percent of individuals with fasting hyperglycemia
are positive for one or more of these markers.
Strong human leukocyte antigen (HLA) associations
also exist.

c. Pre-Diabetes
Individuals, whose blood glucose levels do not
meet the criteria for diabetes but are higher than
those considered normal, are classified as having
pre-diabetes. They have an increased risk of
developing type 2 diabetes, heart disease, and
8
stroke.
Persons with pre-diabetes have impaired glucose
tolerance (IGT) or impaired fasting glucose (IFG)
levels, as described below:
Impaired Glucose Tolerance

The second form of type 1 diabetes, called

idiopathic diabetes, has no known causes. Only
a minority of persons fall into this group, and
they are predominantly of African and Asian
origin. Idiopathic diabetes is strongly inherited,
but it lacks autoimmune markers and it is not
associated with HLA.

A diagnosis of IGT can only be made with the

Oral Glucose Tolerance Test (OGTT), which
measures the bodys ability to metabolize
glucose. Serial testing shows that individuals
with IGT may improve, remain stable, or
worsen. In persons with IGT, the 2-hour
plasma glucose value in the 75-g OGTT is
140 mg/dl (7.8 mmol/L) to 199 mg/dl (11.0
6
mmol/L).

b. Type 2 Diabetes Mellitus

Type 2 diabetes (formerly termed non-insulin
dependent or adult-onset diabetes) occurs when

11

(e.g., stiff man syndrome or anti-insulin-receptor

6
antibodies). These forms of the condition account
for 1 to 5 percent of all diagnosed cases of
8
diabetes.

Impaired Fasting Glucose

IFG signifies the zone between the upper limit
of normal fasting plasma glucose (FPG) and the
lower limit of diabetic FPG. IFG includes those
persons whose fasting glucose is 100 mg/dl
6
(5.6 mmol/L) to 125 mg/dl (6.9 mmol/L).

2. Background
a. Natural History of Diabetes Mellitus

Long used as the test of choice for the

management of diabetes, the glycosylated
hemoglobin (A1C) test is now also recommended
73
for use in its diagnosis. A1C indicates a persons
average blood glucose level for the previous 2
or 3 months by measuring the percentage of
blood glucose attached to hemoglobin. An A1C
test level between 5.7 percent and 6.4 percent is
8
considered pre-diabetes.

The development of diabetes involves several

processes. These range from autoimmune
destruction of beta-cells of the pancreas causing
insulin deficiency to abnormalities that result in
resistance to insulin action. Impairment of insulin
secretion and defects in insulin action frequently
coexist in the same individual. Therefore, it is
often unclear which abnormality is the primary
cause of the hyperglycemia.

d. Gestational Diabetes Mellitus

Type 1 Diabetes Mellitus

Gestational diabetes mellitus (GDM) refers to any

degree of glucose intolerance with onset or first
diagnosis during pregnancy. GDM is caused by
the hormones secreted during pregnancy or by
a shortage of insulin. It occurs predominantly in
African American, Hispanics, and American Indian
women, as well as women who are obese or
9
have a family history of type 2 diabetes.

The rate of beta-cell destruction in type 1

diabetes varies. Some individuals develop
ketoacidosis as the first manifestation of
the disease. Others have modest fasting
hyperglycemia that can change rapidly to
severe hyperglycemia and/or ketoacidosis as
the result of infection or other stress.
Some individuals retain sufficient residual
beta-cell function to prevent ketoacidosis for
many years. However, they eventually become
dependent on insulin for survival. In the later
stage of the disease, there is little or no insulin
6
secretion.

GDM usually is diagnosed during the second or

third trimester. Approximately 5 to 10 percent of
all pregnancies are complicated by GDM. Glucose
tolerance typically returns to normal within 6
weeks after pregnancy ends. Due to the relatively
short and temporary duration of GDM, it does not
lead to the development of diabetic retinopathy.
However, women who have had GDM have a
35 to 60 percent chance of developing type 2
8
diabetes in the subsequent 10 to 20 years.

In type 1 diabetes, persons tend to be acutely

symptomatic at onset, often complaining of
polydipsia, polyphagia, polyuria, unexplained
weight loss and dry mouth.

e. Other Specific Types of Diabetes

Type 2 Diabetes Mellitus

Diabetes can also occur secondary to genetic

defects in beta-cell function or insulin action,
pancreatic diseases or other endocrinopathies,
medications, toxic chemicals, infections, or
uncommon forms of immune-mediated diabetes

The metabolic processes leading to type 2

diabetes occur years or even decades before
the development of hyperglycemia. These
processes progress from an asymptomatic
stage, with insulin resistance, to mild

12

postprandial hyperglycemia, and finally to

diabetes.

or
A random plasma glucose level 200 mg/
dl (11.1 mmol/l) in a person with classic
symptoms of hyperglycemia (polyuria,
polydipsia, and weight loss) or hyperglycemic
crisis. Random is defined as any time of the
day without regard to time since the last meal.

Initially, pancreatic beta-cells can compensate

by increasing insulin levels (hyperinsulinemia),
keeping glucose levels normalized for a period
(up to several years), but eventually IGT
develops for a period of up to several years,
but in mild hyperglycemia, IGT eventually
develops. As compensatory insulin resistance
worsens, greater difficulty with insulin secretion
occurs resulting in increased hyperglycemia.
Together, these defects lead to further
increases in fasting blood glucose. Over time,
the beta-cells are unable to compensate for
74
insulin resistance, resulting in type 2 diabetes.

or
Fasting plasma glucose level 126 mg/dl (7.0
mmol/L). Fasting is defined as no caloric intake
for at least 8 hours.*
or
Two-hour plasma glucose level 200 mg/dl
(11.1 mmol/L) during an OGTT.*

b. Diagnostic Criteria

Due to a lack of a more specific biological

marker to define diabetes, plasma glucose
estimation remains the basis for diagnosis. The
cutoff glycemic levels used to diagnose diabetes
are based on the observed association between
certain glucose levels and a dramatic increase
in the prevalence of microvascular complications
75
(retinopathy and nephropathy).

In the absence of unequivocal hyperglycemia,

these results should be confirmed by repeat
testing.
Gestational Diabetes Mellitus
A 75-g OGTT taken at 24 to 28 weeks of
pregnancy is recommended by the International
Association of Diabetes and Pregnancy Study
Group and the American Diabetes Association
76
(ADA) for diagnosis of gestational diabetes.

For decades, the diagnosis of diabetes has been

based on glucose level criteria, using either the
FPG or the 75-g OGTT. However, A1C testing
is now also considered an accepted method
of diagnosis as it may be a better biochemical
marker for the disease than FPG or 2-hour
73
plasma glucose testing.
The current ADA diagnostic criteria for diabetes
are:

The American College of Obstetricians and

Gynecologists recommends a two-step process
for the screening and diagnosis of GDM. All
pregnant women should be screened by patient
history, clinical risk factors, or a 50-g 1-hour
glucose challenge test at 24 to 28 weeks of
gestation. The diagnosis of GDM can be made
77
on the basis of a 100-g, 3-hour OGTT.

A1C 6.5 percent. The test should be

performed in a laboratory using a method that
is certified and standardized to the Diabetes
Control and Complications Trial (DCCT) assay.*

The ADA recommends that women with a

history of GDM have lifelong screening for the
development of diabetes or pre-diabetes at
78
least every 3 years.

13

C. Epidemiology of Diabetes
Mellitus

obesity, increasing life span, and improved detection

80
of the disease.

1. Prevalence and Incidence

In developing countries, the largest number of people

with diabetes is in the age group 45 to 64 years,
while in developed countries the largest number is
found in those aged 65 and over. Worldwide rates
of diabetes are similar in men and women, although
they are slightly higher in men less than 60 years of
81
age and in women over age 65.

Diabetes mellitus is a large and growing health care

problem in the United States and around the world.
The prevalence of diagnosed and undiagnosed
8
diabetes in the United States (2010) is shown in
Table 1:

a. Type 1 Diabetes Mellitus

Table 1

It is estimated that approximately 20 million people

worldwide, mostly children and young adults, have
type 1 diabetes. The incidence of type 1 diabetes
is increasing at a rate of approximately 3 percent
82
per year.

Prevalence of Diagnosed and Undiagnosed

Diabetes: Americans Aged 20 Years or Older (2010)
Group

Number or percentage who

have diabetes

Aged 20 years or
older

25.6 million, or 11.3% of all

people in this age group

Aged 65 years or
older

10.9 million, or 26.9% of all

people in this age group

Men

13.0 million, or 11.8% of all

men ages 20 years or older

Women

12.6 million, or 10.8% of all

women ages 20 years or
older

Non-Hispanic
Whites

15.7 million, or 10.2% of all

non-Hispanic whites ages 20
years or older

Non-Hispanic
Blacks

4.9 million, or 18.7% of all

non-Hispanic blacks ages 20
years or older

The annual incidence of type 1 diabetes in

children from birth to 16 years of age in
the United States varies with ethnicity and is
approximately 3 to 26 new cases per 100,000
persons. For example, in Blacks in San Diego,
CA, it is 3.3 per 100,000 and in whites
in Rochester, MN, it is 20.6 per 100,000.
Approximately 0.3 percent of the population in the
United States develops the disease by 20 years
83
of age.
b. Type 2 Diabetes Mellitus
Type 2 diabetes is more common in the elderly,
especially those who are overweight. Diabetes
rates vary by race and ethnicity. American Indian,
Alaska Native, Black, Hispanic/Latino, Asian
American, Native Hawaiian and other Pacific
Islander adults are nearly twice as likely as non9
Hispanic white adults to have type 2 diabetes.
People of Caribbean and Middle Eastern descent
also have an increased risk of developing type 2
diabetes.

Source: Centers for Disease Control and Prevention. National

Diabetes Fact Sheet: National estimates and general information
on diabetes and prediabetes in the United States, 2011. Atlanta,
GA: US Department of Health and Human Services, Centers for
Disease Control and Prevention, 2011.

The number of people with diabetes worldwide

increased from 153 million in 1980 to 347 million in
79
2008. This number is expected to grow to
429 million by 2030, owing to the rising frequency of

The annual incidence of type 2 diabetes in the

United States is approximately 2.4 per 1,000
persons over age 20. By 65 years of age, 26.9

14

84

Barr virus, coxsackie virus, mumps virus, or

cytomegalovirus may trigger the autoimmune
destruction of islet cells, or the virus may
directly infect the islet cells.

percent of the population may have type 2 diabetes.

c. Pre-Diabetes

An estimated 35 percent of adults 20 years or

older in the United States have pre-diabetes. The
rate increases to 50 percent of adults aged 65
years or older. Therefore, approximately 79 million
American adults ages 20 years or older have pre8
diabetes.

Autoimmune conditions - Individuals having

another condition that affects the immune
system (e.g., Graves disease, Addisons
disease, celiac disease, Crohns disease,
rheumatoid arthritis).

Impaired Glucose Tolerance

2. Type 2 Diabetes Mellitus

The prevalence of IGT varies among different

age groups and the condition typically is
more common in women than in men. The
prevalence of IGT increases from 2.9 percent
in 30- to 39-year-old men to 15.1 percent in
70- to 79-year-old men; and from 4.5 percent
in 30- to 39-year-old women to 16.9 percent
75
in 70- to 79-year-old women.

The risk factors for type 2 diabetes include:

6,8

Family history of diabetes - First-degree

relatives of individuals with type 2 diabetes are
three times more likely to develop the disease.
Being overweight - Having a body mass
2
index (BMI) 25 kg/m (at-risk BMI may be
lower in some ethnic groups).

Impaired Fasting Glucose

Age - Being 45 years old or older.

The prevalence of IFG also varies among

different age groups and the condition occurs
more frequently in men than in women. It
increases from 5.2 percent in 30- to 39-yearold men to 10.1 percent in 50- to 59-year-old
men and then decreases to 3.2 percent in 80to 89-year-old men. The prevalence increases
from 2.6 percent in 30- to 39-year-old women
75
to 5.9 percent in 70- to 79-year-old women.

Ethnic background - Being African American,

Hispanic/Latino, American Indian, Alaska Native,
Asian American, or Pacific Islander.
Gestational diabetes - Having diabetes while
pregnant or delivering a baby weighing more
than 9 pounds.
Pre-diabetes - Persons with IGT or IFG.

D. Risk Factors for Diabetes

Mellitus

Hypertension - Blood pressure 140/90 mm

Hg.

1. Type 1 Diabetes Mellitus

Abnormal cholesterol levels - HDL level < 35

mg/dl and/or a triglyceride level > 250 mg/dl.

Specific risk factors for type 1 diabetes are unclear.

8
However, possible factors include:
Family history of diabetes - Having a parent
or sibling with type 1 diabetes.
Viral exposure - Exposure to Epstein-

3. Screening for Diabetes Mellitus

Due to the acute onset of symptoms, most cases of
type 1 diabetes are detected soon after the onset
of hyperglycemia. Therefore, widespread clinical
testing of asymptomatic individuals for the presence

15

of autoantibodies related to type 1 diabetes is not

85
recommended as a means to identify persons at risk.
There is no direct evidence supporting the
effectiveness of screening for type 2 diabetes or pre86
diabetes in individuals without risk factors. However,
due to the high prevalence of type 2 diabetes and
the increased morbidity and mortality associated with
the disease, the ADA recommends that all adults
85
aged 45 years and older be screened. In highrisk individuals (as described above), screening at
a younger age should be considered at younger
ages and performed more frequently. In addition, all
pregnant women not known to have diabetes should
be screened for GDM.
Screening using the FPG test following an 8-hour
overnight fast, a 2-hour OGTT (75-g glucose load),
or the A1C test. Individuals whose results are
normal according to a single test, but who have
retinal findings consistent with diabetic retinopathy,
should receive additional laboratory testing to exclude
diabetes. Persons whose results are normal should
6,85
be re-screened at the 3-year point.
Individuals with
positive results need to be retested. Screening of
urine glucose levels is not recommended.
4. Early Detection and Prevention
The Diabetes Prevention Program showed that weight
loss through moderate diet changes and physical
87,88
activity can delay and prevent type 2 diabetes.
People with pre-diabetes who lose 5 to 7 percent
of their body weight and participate in at least 150
minutes a week of moderate physical activity can
reduce the risk of developing type 2 diabetes by 58
89
percent over four years. However, the risk reduction
90
drops to 34 percent after 10 years.
Early detection and treatment can reduce the risk
of complications associated with diabetes. Improving
glycemic control can benefit people with either type
1 or type 2 diabetes. In general, every percentage
point reduction in A1C test results can reduce the
risk of microvascular complications by nearly
60,62,91,92
40 percent.

In addition, control of hypertension reduces the

risk of cardiovascular disease and microvascular
complications. For every 10 mm Hg reduction in
systolic blood pressure, the risk of complications
6,93
related to diabetes is reduced by 12 percent.
Diabetic retinopathy is the leading cause of
preventable vision loss in persons of working age
94
in the United States . Early diagnosis of diabetes
and diabetic retinopathy is essential in reducing
the potential for vision loss. Timely detection and
appropriate treatment of diabetic retinopathy reduces
the risk of severe vision loss (i.e., best corrected
visual acuity of 5/200 or worse) in most individuals
with diabetes.

III. OCULAR COMPLICATIONS OF

DIABETES MELLITUS
A. Diabetic Retinal Disease

iabetic retinal disease, primarily manifesting

as diabetic retinopathy and/or diabetic
macular edema (DME), is the most common
95
microvascular complication of diabetes. Despite
the availability of highly effective treatments, diabetic
retinopathy remains a leading cause of moderate and
severe visual loss among working-aged adults in the
United States and other industrialized countries.
Diabetic retinopathy is a highly specific retinal
vascular complication of diabetes mellitus. It is often
asymptomatic early in the disease, andvisual loss is
primarily due to the development of diabetic macular
edema, vitreous hemorrhage or traction retinal
17
detachment (TRD). Diabetes duration and sustained
hyperglycemia are among the primary risk factors for
96
the development of diabetic retinopathy.

The progression of diabetic retinopathy occurs in

well-defined stages. The condition may progress from
mild non-proliferative diabetic retinopathy (NPDR),
characterized by increased vascular permeability, to
moderate and severe NPDR, with vascular closure,
to proliferative diabetic retinopathy (PDR), with the
growth of new vessels on the retina and posterior
surface of the vitreous. Identifying the severity level

16

of diabetic retinopathy is important for determining

the risk of progression and the appropriate care for
preservation of vision.

older-onset persons with type 2 diabetes were

106
legally blind. The number of Americans 40 years or
older with diabetic retinopathy and vision threatening
diabetic retinopathy is projected to triple by 2050,
from 5.5 million (in 2005) to 16 million for diabetic
retinopathy and from 1.2 million (in 2005) to 3.4
94
million for vision threatening diabetic retinopathy.

Each level of NPDR is associated with a

corresponding risk for progression to PDR and
subsequent risk of severe visual loss.
Diabetic macular edema, which is the most common
cause of vision loss in persons with diabetes, may
be present at any severity level of non-proliferative
or proliferative diabetic retinopathy. Diabetic
macular edema is caused by the breakdown of the
bloodretinal barrier that leads to intraretinal fluid
accumulation in the macula, causing photoreceptor
disruption, and if untreated, increased risk of loss of
28
vision.
Multiple biological pathways have been implicated
in the development of diabetic retinopathy. Current
studies have pointed to specific biochemical pathways,
molecular mechanisms and hemodynamic alterations
in early diabetes mellitus, that include the sorbitol
97
98
pathway, advanced glycation end-products (AGE),
99
100
protein kinase C (PKC) activation, oxidative stress,
101
102
inflammatory markers, retinal blood flow, and
growth factors, such as vascular endothelial growth
103
factor (VEGF). These studies demonstrate that
changes in retinal biochemistry and physiology occur
long before clinically evident disease is observed.

The prevalence of diabetic retinopathy and vision loss

among persons with diabetes is highly associated
with the duration of the disease rather than the
107,108
Diabetic retinopathy occurs more
persons age.
frequently in individuals with longstanding disease
(over 10 years). However, the actual duration of
diabetes for individuals with type 2 diabetes can be
difficult to determine because the initial diagnosis
is typically made after a 5- to 10-year period of
asymptomatic or clinically undetected diabetes. Table
2 summarizes the estimated proportion of persons
with diabetic retinopathy and diabetic macular edema
109-112
by diabetes type and diabetes duration.

1. Epidemiology of Diabetic Retinal Disease and

Vision Loss
Nearly 86 percent of individuals with type 1 diabetes
mellitus and 40 percent of those with type 2
diabetes mellitus have some form of clinically evident
104
diabetic retinopathy.
In 2005 to 2008, an estimated 4.2 million, or 28.5
percent of people with diabetes ages 40 years
and over, had diabetic retinopathy and 655,000 of
this group, or 4.4 percent, had advanced diabetic
105
retinopathy that could lead to severe vision loss.
In the Wisconsin Epidemiologic Study of Diabetic
Retinopathy (WESDR), 3.6 percent of younger-onset
persons with type 1 diabetes and 1.6 percent of

17

Table 2
Duration of Diabetes Mellitus and Presence of Diabetic Retinopathy
and Diabetic Macular Edema
Diabetes Duration of
Disease

Ocular Complication

Type 1

17 to 29% have some retinopathy

Type 2

>

5 years

> 10 years

60% have some retinopathy

> 15 years

78 to 97% have some degree of retinopathy; 25% progress to proliferative

diabetic retinopathy

> 20 years

50 to 60% progress to proliferative retinopathy

> 25 years

29% have diabetic macular edema; 17% have clinically significant macular
edema

At diagnosis

20 to 39% have some retinopathy

>

4% progress to proliferative retinopathy

4 years

> 10 years

25% of individuals on insulin have diabetic macular edema;14% on oral

medications have diabetic macular edema

> 15 years

60 to 80% have some retinopathy; up to 20% progress to proliferative

retinopathy

2. Classification and Signs of Diabetic Retinopathy

the loss of intramural pericytes of the retinal

capillaries, which weakens the capillary walls.

Diabetic retinopathy is broadly classified as nonproliferative diabetic retinopathy (NPDR) and

proliferative diabetic retinopathy (PDR). In addition,
diabetic macular edema (DME) can occur at any
stage of retinopathy.

Retinal hemorrhages are usually caused by

ruptured or leaking microaneurysms or retinal
capillaries. Hemorrhages due to diabetes
typically lie deep in the retina (within the inner
nuclear and outer plexiform layers), wherein
the arrangement of cells is more compact
and perpendicular to the surface of the retina,
causing the hemorrhages to assume a pinpoint
or dot shape.

Characteristic lesions of diabetic retinopathy:

Retinal blood flow alteration is one of the early
changes resulting from diabetes.113,114 However,
changes in retinal blood flow are not readily
observed in routine clinical settings.

Intraretinal microvascular abnormalities (IRMA)

represent either new vessel growth within
the retina or, more likely, pre-existing vessels
with endothelial cell proliferation that serve
as shunts through areas of nonperfusion.

Saccular outpouchings of retinal capillaries,

termed microaneurysms, are frequently the
earliest clinically evident sign of diabetic
retinopathy. These microaneurysms result from

18

The development of severe IRMA commonly

indicates severe ischemia and frank
neovascularization is likely to occur on the
surface of the retina or optic disc within a
short time.

is less than that depicted in ETDRS standard

21,38,40
photograph 2A.
No other diabetic retinal lesion or abnormality
associated with diabetes is present.
Moderate NPDR

Venous caliber abnormalities are indicators of

severe retinal hypoxia. These abnormalities
can take the form of venous dilation, venous
beading (VB), or loop formation. Large areas
of nonperfusion can appear adjacent to
these abnormal veins and are indicative of
a substantial risk factor for progression to
proliferative diabetic retinopathy.

Moderate NPDR is characterized by H/Ma

greater than that depicted in ETDRS standard
photograph 2A in one to three retinal quadrants and/or soft exudates, VB, or IRMA defi38,40
nitely present.
Severe NPDR

The growth of new vessels, either at or near

the optic disc (NVD), or elsewhere in the retina
(NVE), signify the presence of proliferative
diabetic retinopathy, with an increased risk for
visual loss due to the development of vitreous
hemorrhage or traction retinal detachment.

Severe NPDR is based on the extent and

severity of H/Ma, VB and IRMA, and is
characterized by any one of the following
lesions:
H/Ma than ETDRS standard photograph
2A in four retinal quadrants.

The following classification of diabetic retinopathy

and diabetic macular edema is based on the ETDRS
38,40
grading system
for diabetic retinopathy and
DME. (See Appendix Figure 3 for ETDRS standard
photographs 2A, 6B, 8A, 10A and macular edema).

VB (exemplified by that in standard

photograph 6B) in two or more retinal
quadrants.

a. Non-proliferative Diabetic Retinopathy (NPDR)

Non-proliferative diabetic retinopathy is
characterized by the presence of hemorrhages
and/or microaneurysms (H/Ma), hard exudates
(HE), soft exudates (cotton wool spots), intraretinal
microvascular abnormalities (IRMA), venous looping,
and/or venous beading (VB). In the absence of
macular edema or ischemia, NPDR typically does
not present a threat to vision. However, the
presence of severe H/Ma, VB, and IRMA confers
a substantial risk for progression to PDR, with
a corresponding increased risk for severe vision
40
loss. (See Table 3).

Prominent IRMA ( than ETDRS standard

photograph 8A) in at least one retinal
38,40
quadrant.
This 4-2-1 rule is an important clinical tool
for determining the risk of progressing to
proliferative diabetic retinopathy.
Very Severe NPDR
In very severe NPDR, two or more criteria for
severe NPDR are met, in the absence of frank
neovascularization.
b. Proliferative Diabetic Retinopathy (PDR)
The most severe sight-threatening form of diabetic
retinopathy is proliferative diabetic retinopathy.
Most individuals with PDR are at substantial
risk for severe vision loss. Without appropriate
treatment, 50% of eyes with PDR are blind within

Mild NPDR
Mild NPDR is marked by at least one retinal
microaneurysm. However, the severity of H/Ma

19

5 years, as reported by ETDRS.

NVE > one-half DA in size with VH or PRH

present.

Characteristics of PDR include new vessels on or

within one disc diameter of the disc (NVD), new
vessels elsewhere on the retina i.e. not on or
within one disc diameter of the optic disc (NVE),
fibrous proliferation on or within one disc diameter
of the optic disc (FPD) or elsewhere on the retina
(FPE), preretinal hemorrhage (PRH), and/or vitreous
38,40
hemorrhage (VH).

Table 3 provides a listing of the 1- and 5-year

course of progression for the levels of diabetic
retinopathy. The risk for progression described
in Table 3 is based on estimates derived from
the ETDRS, which was conducted in the 1980s.
Current risk for progression may be lower given
changes in management of diabetes that have
resulted in overall improved glycemic, blood
105,115
pressure and lipid control.

PDR
Early proliferative diabetic retinopathy has one
or more of the following:
NVE or NVD < ETDRS standard
photograph 10A.
PRH and NVE < one-half disk area (DA),
without NVD.
High-Risk PDR
High-risk PDR is characterized by one or more
of the following:
NVD > one-fourth to one-third DA in size
(ETDRS standard photograph 10A).
NVD < one-fourth DA in size with fresh VH
or PRH present.

Mild NPDR

Table 3
Natural Course Rate of Progression to
PDR (1 year)
HR PDR (5 years)
5%
15%

Moderate NPDR

12 to 27%

33%

Severe NPDR

52%

60 to 75%

Severity of Condition

Non-high-risk PDR

75%

Twenty-five to forty percent of individuals with high-risk proliferative diabetic retinopathy (HR PDR) develop
severe vision loss within 2 years.

20

B. Non-retinal Ocular
Complications

c. Diabetic Macular Edema

Diabetic macular edema (DME) is the collection of
intraretinal fluid in the macular area of the retina,
with or without lipid exudates or cystoid changes.
Visual acuity is generally compromised when DME
affects the fovea.

1. Classification and Signs of Non-retinal Ocular

Complications
Diabetic eye disease is an end-organ response to a
systemic medical condition. All structures of the eye
and many aspects of visual function are susceptible
to the deleterious effects of diabetes. These effects
are summarized as follows:

Macular edema is classified as:

Macular Edema
Retinal thickening within two disk diameters
(DD) of the center of the macula.

a. Visual Function
Loss of visual acuity

Clinically Significant Macular Edema (CSME)

Reductions in visual acuity can occur due

to refractive shifts, cataracts, ischemic optic
neuropathy, papillopathy, macular edema, ocular
surface disease, or other diabetes-related ocular
changes.

One or more of the following are present:

Thickening of the retina 500 microns
(1/3 DD) from the center of the macula.
Hard exudates 500 microns (1/3 DD)
from the center of the macula with
thickening of the adjacent retina.

Refractive error changes

A zone or zones of retinal thickening

1 DA in size, any portion of which is
31
1 DD from the center of the macula.
The term clinically significant macular edema
(CSME) was introduced in the ETDRS to signify
an increased risk for moderate visual loss (defined
as doubling of the visual angle, e.g. from 20/40
to 20/80).28 A further increased risk for visual loss
was observed in eyes with DME that have retinal
thickening involving the center of the macula
(center-involved DME), which is an important factor
in determining short- and long-term visual acuity
outcomes. Data from the ETDRS have shown
that by one year of follow-up, eyes with centerinvolved CSME had nearly a ten-fold greater risk
for developing moderate visual loss compared
to eyes without center involvement, stressing the
importance of determining center involvement in
eyes with macular edema.

21

Persons with diabetes may experience

transient changes in their refractive status.
The fluctuations may be myopic or hyperopic
in association with hyperglycemia or hypo116,117
glycemia.
These changes are thought to
involve fluid absorption by the crystalline lens.
Refractive shifts often occur as a symptom
or sign of undiagnosed diabetes. This shift
can be several diopters or more. Regardless
of the magnitude or direction of the changes,
the refractive status tends to normalize within
118
weeks of initiation of treatment for diabetes.
Changes in color vision
Color vision changes may appear in
persons with diabetes and can precede the
development of diabetic retinopathy. Acquired
color vision changes can occur in both blueyellow and red-green discrimination and,
when diabetic retinopathy is present, have
been shown to correlate with the duration of
119
diabetes.

and may be unable to abduct past the mid-line.

Patients may turn their heads in the direction of
their paretic field of action in order to eliminate
diplopia.

Accommodative dysfunction
Accommodative ability may be altered in
120
persons with diabetes. A decrease of
accommodation is usually transient and
improves with control of glucose levels.

Persons with fourth nerve palsy usually complain

of vertical diplopia, which is typically sudden in
onset and initially worsens. The vertical deviation
increases with downward gaze or lateral gaze
away from the affected muscle when the head is
tilted toward the side of the affected muscle.

A reduction in accommodation has also been

reported in persons who undergo panretinal
120
(scatter) laser photocoagulation.
Visual field changes

Full ocular motility recovery generally occurs within

118,120
three to six months.
However, recurrences are
123
common.

Loss of visual field can occur in individuals with

diabetes secondary to preretinal and vitreous
hemorrhages, new vessel growth and fibrous
proliferation on the retina, neovascular or
primary open angle glaucoma, posterior vitreous
detachment, papillopathy, or ischemic optic
121
neuropathy.

c. Pupillary Reflexes
Diabetes may affect sympathetic innervation of the
iris. Persons with diabetes may exhibit sluggish
118
pupillary reflexes. Also, pupils may be more
miotic and have a weaker reaction to topical
mydriatics.

In addition, persons undergoing scatter

(panretinal) laser photocoagulation may
122
experience a reduction in their visual fields.

d. Conjunctiva

b. Eye Movement Anomalies

Microaneurysms in the bulbar conjunctiva are more

common in persons with diabetes. In addition,
individuals with diabetes are at increased risk of
118
developing conjunctival bacterial infections.

Ocular motility disorders may occur in individuals

with diabetes secondary to diabetic neuropathy
involving the third, fourth or sixth cranial nerves.
Mononeuropathies present a significant diagnostic
challenge, since a substantial number that occur
in persons with diabetes are not due to the
120
diabetes itself. Therefore, other potential causes
need to be ruled out.

e. Tear Film
Tear film abnormalities occur frequently in persons
with diabetes, leading to an increased incidence of
118
dry eye. Tear break-up time may be diminished,
affecting tear film stability. The presence of an
abnormal tear film may contribute to discomfort
and to the increased risk of ocular surface
epithelial defects.

Palsies of the third nerve are generally more

common than fourth or sixth nerve palsies.120
They generally are accompanied by a ptosis,
with exotropia and hypotropia of the affected
eye. Acute pain may be associated with onset
of the palsy. Pupil sparing is also an important,
but not the only, diagnostic feature in helping to
distinguish diabetes-related third nerve palsy from
intracranial aneurysms or tumors.

In addition, persons with diabetes may exhibit

reduced corneal sensitivity, due to neuropathy of
the ophthalmic division of the trigeminal nerve,
118
which may reduce reflex tear secretion, decrease
subjective symptomatology and increase risk of
neurotrophic keratitis. Longstanding diabetes may
also damage the mircrovascular supply to the

Persons with sixth nerve palsy usually present with

horizontal diplopia. The affected eye is esotropic

22

lacrimal gland, impairing lacrimation.

diabetes need to be evaluated initially and on a

continuing basis by their eye care provider.

f. Cornea

g. Iris

Corneal wound healing

The cornea of a person with diabetes is more
susceptible to injury and slower to heal after
injury than the cornea of a person without
120
diabetes. Therefore, persons with diabetes
are at higher risk of corneal complications,
including superficial punctate keratitis, recurrent
corneal erosions, persistent epithelial defects
and corneal endothelial damage. These
complications have been linked to tear
secretion abnormalities, decreased corneal
sensitivity, and poor adhesion between epithelial
cells and the basement membrane.
Reduced corneal sensitivity

Depigmentation
Depigmentation of the iris may result in
118
pigment deposits on the corneal endothelium.
Neovascularization of the iris (Rubeosis iridis)
Neovascularization of the iris (NVI) is a serious
complication marked by a growth of new
blood vessels. These vessels are usually first
observed at the pupillary margin, but may be
present in the filtration angle without any visible
vessels on the pupil border. NVI can involve
the entire iris surface and angle.

Persons with diabetes often have reduced

118,120
corneal sensitivity.
This may result in
increased susceptibility to corneal ulceration or
abrasion in individuals with dry eye syndrome
or in those who wear contact lenses.

If NVI progresses, a fibrovascular network of

vessels may grow over the iris tissue and into
the filtration angle of the eye. The new vessels
and accompanying fibrosis may occlude the
trabecular meshwork, resulting in neovascular
glaucoma.

Corneal abrasions

Neovascular glaucoma

Corneal abrasions in persons with diabetes

are more likely to be recurrent and to involve
detachment of the basement membrane.118
In addition, persons with diabetes experience
delayed re-epithelization of the cornea due to
abnormal adhesion of the epithelium to the
underlying basement membrane.

Studies have shown a consistent association

between diabetes and neovascular glaucoma
(NVG). NVG is a sequella of PDR that is
thought to develop because of VEGF-induced
126
neovascularization of the iris and angle.
h. Lens

Contact lens wear

Cataracts

Diabetes increases the risk of contact lensrelated microbial keratitis, especially in those
118
who use extended wear contact lenses.
In addition, persons with diabetes may not
recover as readily from contact lens-induced
corneal edema. However, studies have
concluded that daily wear contact lenses are
a safe option for vision correction for persons
124,125
with diabetes.
However, individuals with

Cataracts are a major cause of vision

impairment in people with diabetes and tend
to develop earlier and progress more rapidly,
120
compared to persons without diabetes. The
risk of cataract development increases with
the duration of diabetes and the severity of
123
hyperglycemia.

23

127-129

Studies
have reported an increased
prevalence and incidence of posterior
subcapsular and cortical cataracts in persons
with diabetes. Deposition of advanced glycation
end-products (AGEs) in the lens has been
postulated as one possible mechanism for
diabetic cataract.

changes in the vitreous. The vitreous may exert

traction on these vessels resulting in vitreous
hemorrhage.
Proliferative diabetic retinopathy is associated with
an increased incidence of PVD. Partial vitreous
detachment may result in vitreous hemorrhage, an
increase in retinal neovascularization and tractional
120
retinal detachment.

Type 2 diabetes is strongly associated with

the development of nuclear sclerosis and
cortical cataract. Compared with nondiabetic
persons, individuals with type 2 diabetes have
a substantially higher use of statins, which are
associated with the development of age-related
cataracts (nuclear sclerosis and posterior
subcapsular cataract). In addition, cataracts
tend to occur earlier in persons with type 2
diabetes using statins, compared with persons
130
without diabetes who dont use statins.

j. Optic Disc
Papillopathy
Diabetic papillopathy is a distinct clinical entity
that must be distinguished from papilledema or
132
other etiologies of optic disc swelling. The
papillopathy is characterized by unilateral or
bilateral hyperemic disc swelling, which may
present with or without an afferent pupillary
133
defect or visual field defect.

Metabolic Syndrome (MetS) has also been

found to contribute to an increased incidence
of cortical cataracts and posterior subcapsular
cataract over 5 years. Among MetS
components, low HDL cholesterol has been
linked to an increase in the 10-year incidence
of cortical cataract and elevated glucose was
positively associated with the incidence of
131
posterior subcapsular cataract over 10 years.

Diffuse microangiopathy may be associated

with the etiology of diabetic papillopathy,
although there appears to be no correlation
between diabetic papillopathy and either the
degree of diabetic retinopathy or the level of
132-134
clinical control of the individuals diabetes.
However, diabetic papillopathy is a risk factor
123
for the progression of diabetic retinopathy.

Reversible opacities and snowflake cataracts

Visual acuity is usually moderately reduced

and the prognosis for improvement upon
resolution is good. In most individuals, diabetic
papillopathy resolves without treatment within a
year and visual acuity improves to a level of
123
20/30.

Although rare, reversible lenticular opacities

related to diabetes have been reported and are
frequently related to poor metabolic control of
diabetes. These cataracts are usually bilateral
and are characterized by dense bands of
white, subcapsular spots that are snowflake in
123
appearance.

Ischemic optic neuropathy

Diabetes represents an independent risk factor
for the development of nonarteritic anterior
ischemic optic neuropathy (NAION) and has
been shown to increase the risk of NAION
135
among individuals over 67 years of age.

i. Vitreous
Persons with diabetes may exhibit vitreous
degeneration and posterior vitreous detachment
(PVD), which may play a role in PDR. New vessel
growth on the surface of the retina may project
into the posterior vitreous causing biochemical

Diabetes-related anterior ischemic optic

neuropathy usually presents with optic disc

24

pallor, swelling and hemorrhages, sudden

decreased vision, an afferent pupillary defect,
and an altitudinal visual field defect. The
condition often results in optic atrophy and
reduced visual acuity. The clinical appearance
of early anterior ischemic optic neuropathy
is difficult to distinguish from diabetic
133
papillopathy, although younger age is more
consistent with the latter. Persons with diabetes
are also susceptible to retrobulbar ischemic
optic neuropathy. As many as 25 percent of
persons with anterior ischemic optic neuropathy
123
have a history of diabetes.

IV. DIAGNOSIS OF OCULAR

COMPLICATIONS OF DIABETES
MELLITUS

Open angle glaucoma

An eye examination may be the basis for the initial

diagnosis of the individual who is unaware of having
a diabetic condition.

Diabetes has been found to be associated with

elevated intraocular pressure (IOP). However,
current evidence suggesting that diabetes is a
118
risk factor for glaucoma is conflicting.

he components of patient care described in this

Guideline are not intended to be all-inclusive.
Professional judgment and individual patient
symptoms and findings may have a substantial
impact on the nature, extent and course of the
services provided and/or recommended.

A. individuals with Undiagnosed

Diabetes Mellitus

1. Patient History

Diabetes can influence ocular vasculature in

individuals with open angle glaucoma and may
contribute to the disease process. Persons with
diabetes who have open angle glaucoma (OAG)
may have lower retrobulbar flow in the central
retinal artery, as well as possible higher retinal
microcirculation flow, specifically in the inferior
retinal sector. These ocular diabetic vascular
abnormalities could contribute to glaucomatous
136
optic neuropathy.

The patient history is used to investigate any ocular

and systemic complaints and symptoms related to
diabetes:
Common ocular symptoms of undiagnosed
diabetes may include the recent onset of visual
changes. Individuals may report blurred or
fluctuating vision, improved near vision if they
have a myopic shift and are presbyopic or
new-onset diplopia. Symptoms of ocular surface
disease and staphylococcal eyelid disease
may also be more common, as a function of
hyperglycemia.

In addition, persons with diabetes often have

concomitant hypertension that may potentially
affect vascular perfusion of the optic nerve
head. Formation of advanced glycation endproducts (AGEs) within the trabecular meshwork
and the lamina cribrosa of the optic nerve
may further increase the risk of both ocular
hypertension and damage to the optic nerve
137
axons.

Systemic symptoms may include polyuria,

polydipsia, polyphagia, unexplained weight
changes, dry mouth, pruritus, leg cramps or
pains, erectile dysfunction in men and reduced
sexual response in women, delayed healing of
bruises or wounds, and recurrent infections of
the skin, genitalia, or urinary tract.
2. Diabetes Risk Assessment
Noninvasive risk assessment tools are available to
help identify people at risk for the development
of type 2 diabetes. These tools provide a risk

25

rating based on answers to a number of questions

regarding variables such as age, gender, race,
weight, body mass index (BMI), blood pressure,
physical activity, and family history of diabetes.
Diabetes risk scores can be used to identify
individuals with undiagnosed type 2 diabetes who
might benefit from more comprehensive assessment,
138
such as determination of blood glucose levels.
Examples of validated risk assessment tools include
139
the Diabetes Risk Calculator* and the Weill-Cornell
Medical College Patient Self-Assessment Score for
140
Diabetes.**
It should be noted that these tools are not
diagnostic and further testing should be done to
achieve a definitive diagnosis.
* The Diabetes Risk Calculator can be accessed online
** The Weill-Cornell Medical College Patient Self-Assessment
Score for Diabetes can be accessed online

3. Ocular Examination
ACTION: The ocular examination of an individual
suspected of having undiagnosed diabetes
should include all aspects of a comprehensive
eye examination** with supplemental testing, as
needed.

evaluation, or an A1C test or fasting blood

glucose analysis may be ordered.
There is little direct evidence that identifying persons
with pre-diabetes will lead to long-term health
86
benefits. (A/B) However, early identification and
control of hyperglycemia and high blood pressure
can prevent or delay long-term microvascular
141
complications of diabetes. (B/B) Tight glycemic
and blood pressure control are the cornerstones of
142
primary prevention of diabetic retinopathy. (A/A)
****Authority of Optometrists to Order Lab and Other
Diagnostic Tests Unless there is a specific limitation
in the Optometry Act or other section of state law
regarding which diagnostic, laboratory, radiology or
other tests they may order, optometrists may order
any tests rational to the diagnosis of conditions of
the eye, adjacent structures, the vision system, or for
systemic conditions affecting the eyes, as defined by
the applicable standard of care.
American Optometric Association, State Government
Relations Center, July 2009

B. Individuals with Diagnosed

Diabetes Mellitus
ACTION: The ocular examination of a person
with diabetes should include all aspects of
a comprehensive eye examination,*** with
supplemental testing, as indicated, to detect and
thoroughly evaluate ocular complications.

***Refer to the Optometric Clinical Practice Guideline for

Comprehensive Adult Eye and Vision Examination

If, on the basis of the results of the eye examination

or risk assessment tools, diabetes is suspected, the
patient should be referred to his or her primary care
physician for further evaluation, or an A1C test or
fasting blood glucose analysis may be ordered.****
The use of A1C testing may help predict those
at-risk for diabetes, diabetic retinopathy or other
73
complications of diabetes. (C/B)

***Refer to the Optometric Clinical Practice Guideline for

Comprehensive Adult Eye and Vision Examination

1. Patient History
The patient history includes a review of both the
ocular and systemic status of the patient:
Quality of the patients vision - including
symptoms such as blurred, distorted, or
fluctuating vision, diplopia, night vision problems
and flashes or floaters.

ACTION: Persons without a diagnosis of

diabetes who present with signs suggestive of
diabetes during the initial examination should
be referred to their primary care physician for

26

 Ocular history - including previous ocular

trauma, disease or surgery that might
contribute to ocular complications associated
with diabetes.
Medical history - including obesity, pregnancy,
and current medication taken. (See Appendix
Table 2: Effect of Systemic Medications on
Onset and Progression of Diabetic Retinopathy
Duration of diabetes - the risks for ocular
complications are closely related to the
107-108
duration of the diabetes.
Age at the time
of onset of diabetes is not as significant as
the duration of the disease in the prediction of
109,110,143
complications.
Recent values for the ABCs of diabetes
- A1C, blood pressure and cholesterol
levels, and smoking. The A1C level, at initial
examination, has been shown to be a strong
predictor of the incidence and progression of
any retinopathy or progression to proliferative
144,145
retinopathy.

60,61,144

development of ocular complications.

The presence of retinopathy, regardless of the

persons diabetes status, may also indicate other
146
underlying subclinical vascular disease. (B/B) The
clinician should consider other etiologies, especially
cardiovascular disease, hypertension and smoking
147
status. (B/B)
ACTION: Patients should be questioned about
the awareness of their personal diabetes ABCs
(A1C, blood pressure, and cholesterol levels and
their history of smoking).
Additional information useful for patient assessment
includes a review of other medical problems, all
prescribed medications, use of nutritional supplements
and history of allergy to medications.
Contact information for the patients other health care
providers should be noted in their record to facilitate
communication and coordination of care, when
appropriate.
2. Ocular Examination

In addition, individuals should be questioned

about their use of tobacco. Smoking may be
considered the final letter(s) in the ABCs of
diabetes.

ACTION: The initial ocular examination should

include, but is not limited to, the following
evaluations:
Best-corrected visual acuity

The patients prescribed management of

diabetes, including:

Pupillary reflexes

1. Medical nutrition therapy

Ocular motility

2. Exercise and physical activity

Refractive status

3. Oral or injectable medications

Confrontation visual field testing or visual field

evaluation

4. Insulin type, dosage and timing of

administration

Slit lamp biomicroscopy

5. Method, frequency and results of selfmonitoring of blood glucose.

Tonometry
Dilated retinal examination

This information provides insight into the

patients adherence to therapeutic regimens
and control of diabetes, which may affect the

27

Tonometry
The central cornea of persons with diabetes may
be thicker than in persons without diabetes. This
possibility needs to be taken into consideration when
measuring intraocular pressure in individuals with
148
diabetes to ensure accuracy of measurement.
In addition, persons with diabetes may display altered
corneal biomechanics related to blood glucose
concentrations. They may have significantly higher
corneal response factors (CRF), which is strongly
associated with corneal stiffness and may also alter
149
tonometry readings.
Dilated Retinal Examination
Binocular indirect ophthalmoscopy or slit lamp
biomicroscopy with condensing lens should be
performed to examine the retina thoroughly for the
presence of diabetic retinopathy.

retinal neovascularization and hard exudates or

thickening in the macula. The presence and severity
of these lesions determines the level of diabetic
retinopathy and diabetic macular edema.
ACTION: When vitreous hemorrhage prevents
adequate visualization of the retina, prompt
referral to an ophthalmologist experienced in the
management of diabetic retinal disease should be
made for further evaluation.
*Click this link for the protocol for color coding retinal drawings

3. Supplemental Testing
Additional procedures in diagnosing and evaluating
diabetic retinopathy may be indicated. Such
procedures include, but are not limited to:
Fundus photography or retinal imaging
Mydriatic ETDRS 7-field stereo 35 mm
fundus photography is the gold standard
for evaluating the presence and severity of
diabetic retinopathy and DME. The transition
to digital imaging, while utilizing the same
imaging technique, has been shown to maintain
150,151,152
comparable levels of agreement.
(A/A)

ACTION: Retinal examinations for diabetic

retinopathy should be performed through a
dilated pupil.
Clinicians should use caution in administering topically
applied drugs for pupillary dilation in pregnant
women. Topically applied drugs for pupillary dilation,
such as tropicamide, hydroxyamphetamine and
phenylephrine are Pregnancy Category C drugs.
When evaluation through a dilated pupil is necessary
to assess diabetic retinal changes or unexplained
decreased vision during pregnancy, the benefits of
dilation may outweigh any potential risks. The use
of digital punctual occlusion can minimize systemic
absorption.

Retinal imaging following defined validated

protocol for image acquisition and evaluation
has been shown to correlate well with
dilated stereoscopic examination by a trained
153
examiner. (C/B) Stereoscopic photography
is useful for identifying lesions of diabetic
retinopathy and for documenting retinal status.
The results of digital and film evaluations of
diabetic retinopathy have been shown to be
comparable for ETDRS severity levels and
152
DCCT/EDIC study design outcomes. (A/A)
Similarly, the use of standardized retinal video
recording evaluated using a defined protocol
has been shown to be comparable to standard
retinal photography in imaging and evaluating
154
for diabetic retinopathy. (B/B)

Proper documentation of retinal status, including the

use of drawings or color photographs in the patients
record, is valuable for determining any progression
or stability of the retinopathy at future examinations.
Use of the standard protocol for color-coding retinal
drawings is recommended.*
It is advisable to note the presence (and the severity)
or the absence of neovascularization of the iris
(rubeosis iridis or NVI), retinal H/Ma, VB, IRMA,

28

 Optical coherence tomography

Optical coherence tomography (OCT) is
particularly useful in quantifying the degree
of retinal thickening and for identifying retinal
thickening that may not have been evident on
155
clinical examination. Also, OCT has become
nearly indispensable in routine clinical practice
to evaluate macular edema and vitreo-retinal
156-159
interface abnormalities.
However, data
suggest routine macular OCT imaging is not
indicated in persons with no retinopathy or mild
to moderate diabetic retinopathy, when retinal
160
thickening is absent on clinical examination.
Use of the OCT is an important tool in
assessing DME, especially for monitoring the
153
efficacy of treatment. (C/B) However, clinicians
should be aware that substantial discrepancies
often exist between OCT results and the
161
clinical examination of DME. (B/B)

arteriolar abnormalities are associated with

retinopathy severity and with the likelihood of
41
progression to proliferative retinopathy. (A/A)
Fluorescein angiography can also be used for
determining the presence of foveal ischemia
in cases where vision is reduced beyond
that expected based on ophthalmoscopic
appearance of the macula. However, fluorescein
angiography is not indicated to confirm a
164
suspected clinical diagnosis of PDR (B/B)
and should not be used for routine diabetic
39
retinopathy evaluation. In addition, the use of
FA for assessing DME is not recommended,
since it offers little additional information beyond
153
that provided by OCT imaging. (C/B) However,
FA may be helpful in guiding treatment of
DME.
Fundus autofluorescence
Fundus autofluorescence (FAF) is a
noninvasive in vivo imaging method for
metabolic mapping of fluorophores of the
fundus. FAF is increasingly used to detect
and objectively quantify disease severity in
patients with nonexudative age-related macular
165
degeneration. Evidence suggests that FAF
may provide information beyond that obtained
by fundus photography, fluorescein angiography
166
and OCT in eyes with DME. However,
usefulness of FAF for assessing and managing
diabetic retinal disease remains uncertain.

The assessment of macular thickness using

OCT is clinically useful and demonstrates the
degree of macular edema. However, central
macular thickness only shows moderate
correlation with visual acuity in eyes with
162
DME. This finding indicates that functional
and structural determinants of visual function
other than retinal thickness are present in
quantifying visual loss from DME.
The use of central macular thickness, as
measured by OCT, is not indicated in isolation
to identify central CSME or to make treatment
161
decisions in persons with DME. (B/B) In
patients with DME, spectral domain OCT
provides easier observation of normal and
abnormal retinal and vitreo-retinal findings than
163
does time domain OCT. (C/B)

Ocular ultrasound
Ocular ultrasound (ultrasonography) can be
helpful in detecting retinal detachment when
viewing of the retina is obscured by cataract,
vitreous hemorrhage or other media opacity.
Contrast sensitivity testing

Fluorescein angiography
Fluorescein angiography (FA) may be used to
identify vascular leakage and treatable lesions in
eyes with DME. Fluorescein leakage (particularly
diffuse), capillary loss and dilation and various

29

Contrast sensitivity testing can be used as an

early indicator of changes in the retina not
167
shown by visual acuity measurements. Deficits
in contrast sensitivity may occur before the

168

Level of patient adherence to, and

understanding of, their treatment plan

onset of clinically detectable retinopathy.

Blood pressure measurement

Concurrent medical status

As hypertension is more prevalent in persons

with diabetes and is a potential risk factor for
the development and progression of diabetic
87,169
retinopathy,
blood pressure may be
measured at the time of the eye examination,
particularly in individuals who may not be under
regular medical care.

Both non-retinal and retinal ocular findings and

symptoms
Subjective changes in vision
ACTION: As diabetes may go undiagnosed
for many years, any individual with type 2
diabetes should have a comprehensive dilated
eye examination soon after the diagnosis of
78
diabetes.

Slight variations in optimum blood pressure

for people with diabetes are found in the
literature. Blood pressure of <140/80 mmHg
has been recommended for most patients
with diabetes.78 No evidence was shown
that a more aggressive blood pressure goal
(e.g. systolic blood pressure <130 mmHg) is
170
beneficial. (A/B)
Color vision testing
Changes in color perception may occur in
persons with diabetes. Therefore, color vision
testing may be appropriate. However, the use
of color vision testing for the diagnosis of
171
diabetic retinopathy is not recommended. (B/B)
ACTION: The individuals primary care physician
should be informed of eye examination
results following each examination, even when
retinopathy is minimal or not present.

C. Ocular Examination Schedule

1. Persons with Diabetes Mellitus

ACTION: Individuals with diabetes should receive

at least annual dilated eye examinations. More
frequent examination may be needed depending
on changes in vision and the severity and
progression of diabetic retinopathy.
The clinical signs of diabetic retinopathy can
appear early in the natural history of the disease.
Unfortunately, individuals may not experience
symptoms until relatively late, at which time treatment
may be less effective. The success of appropriate
intervention and management strategies depends
upon accurate and timely detection of diabetic eye
disease.
The main risk factor of diabetic retinopathy worsening
during pregnancy is the baseline severity of diabetic
60,172
retinopathy.
(C/B) In general, individuals with
GDM do not develop retinopathy. Therefore, retinal
evaluation for diabetic retinopathy in these patients is
not indicated.
ACTION: Women with pre-existing diabetes who
are planning pregnancy or who become pregnant
should have a comprehensive eye examination
prior to a planned pregnancy or during the first
trimester, with follow-up during each trimester of
pregnancy.

The frequency of ocular examination is determined on

the basis of several factors, including, but not limited
to:
Type of diabetes
Duration of the disease
Age of the patient

30

2. Persons with Non-retinal Ocular Complications of

Diabetes Mellitus
ACTION: Examination of persons with nonretinal ocular complications of diabetes should be
consistent with current recommendations of care
for each condition.
See Table 5 for a brief outline of the management of
non-retinal ocular complications.
3. Persons with Retinal Complications of Diabetes
Mellitus
Mild NPDR (with no DME)

Follow-up every 2 to 3 months in consultation with

an ophthalmologist experienced in the management
of diabetic retinal disease is recommended.
ACTION: Prompt referral to a vitreo-retinal
surgeon is indicated when a vitreous hemorrhage,
a retinal detachment or other evidence of
proliferative diabetic retinopathy is present.
A summary of follow-up visits for management of
patients with retinal complications of diabetes can
be found in Table 4. Patient education and written or
electronic communication with the patients primary
care physician are integral to the management of
diabetic retinopathy.

An annual dilated eye examination is generally

sufficient for monitoring the patient with mild NPDR,
as long as there are neither DME nor coincident
medical risk factors such as hypertension, renal
disease or pregnancy, that may predispose patients
to progression.
Moderate NPDR
For patients with moderate NPDR, fundus
photography is strongly suggested, and repeat
evaluation in 6 to 8 months is appropriate in the
absence of DME or complicating medical or risk
factors.
If DME is present, but does not meet the criteria for
CSME, follow-up every 2 to 4 months is advisable.
Severe or Very Severe NPDR
Follow-up every 2 to 3 months in consultation with
an ophthalmologist experienced in the management
of diabetic retinal disease is advisable for patients
with severe or very severe NPDR.
Proliferative Diabetic Retinopathy
Consultation with an ophthalmologist experienced
in the management of diabetic retinal disease is
indicated if PDR or DME is suspected or if there is
an unexplained loss of visual acuity.

31

TABLE 4:
Frequency and Composition of Evaluation and Management Visits for
Retinal Complications of Diabetes Mellitus
Severity of
Condition

Natural Course
Rate of Progression
to
PDR
(1 year)

Mild NPDR

5%

Frequency of
Follow-up

HRC *
(5 years)

Components of Follow-up
Evaluations
Fundus
Photography

OCT/
Fluorescein
Angiography

15%

No macular edema

12 months

No

No

Macular edema

4 to 6 months

Yes

Based on clinical
judgment

CSME

2 to 4 months**

Yes

Yes

No macular edema

6 to 8 months

Yes

No

Macular edema
(not CSME)

4 to 6 months

Yes

Based on clinical
judgment

CSME

2 to 4 months**

Yes

Yes

No macular edema

3 to 4 months

Yes

No

Macular edema (not

CSME)

2 to 3 months

Yes

Based on clinical
judgment

CSME

2 to 3 months**

Yes

Yes

No macular edema

2 to 3 months

Yes

No

Macular edema
(not CSME)

2 to 3 months

Yes

Based on clinical
judgment

CSME

2 to 3 months**

Yes

Yes

No macular edema

2 to 3 months

Yes

No

Macular edema

2 to 3 months

Yes

Based on clinical
judgment

Moderate NPDR

Severe NPDR

Very Severe NPDR

Non-high-risk PDR

12-27%

52%

75%

33%

60-75%

75%

75%

32

TABLE 4 (continued)
CSME

2 to 3 months**

Yes

Yes

No macular edema

2 to 3 months

Yes

No

Macular edema

1 to 2 months

Yes

Yes

CSME

1 to 2 months**

Yes

Yes

High-risk PDR

*HRC = High-risk category

**Follow-up is typically monthly for the first year of treatment if intravitreal anti-VEGF injections are given.
screened for high blood glucose levels:

4. Clinical Recordkeeping
Electronic Health Records (EHRs) are helpful for
identifying at-risk populations for preventive care and
173
intervention. (B/B) The use of EHRs to support
clinical decision-making has been shown to improve
glucose control and some aspects of blood pressure
174
control in adults with type 2 diabetes. (B/B)

A1C values between 4.0 percent and 5.6

percent usually indicate adequate blood
glucose levels. Values between 5.7 percent
and 6.4 percent are considered pre-diabetes.
Values of 6.5 percent or greater indicate the
need for further evaluation or treatment.

When compared to paper record-based practices,

the use of electronic health records (EHRs) may
improve the quality of care and outcomes for
175
patients with diabetes. (C/B) EHRs can also be
used to identify clusters of risk factors for diabetes
and coronary heart disease in patients in large health
173
care networks. (B/B)

A patient with fasting blood glucose values of

greater than or equal to 110 mg/dl, but less
than 126 mg/dl, has IFG and needs to be
retested. Fasting blood glucose values of 126
mg/dl or greater indicate the need for further
evaluation or treatment.
Most pregnant women should be screened for
glucose intolerance. Because as a pregnant
patient is usually under medical care, her prenatal
care provider should coordinate this evaluation.

V. TREATMENT AND MANAGEMENT

A. Management of Ocular
Complications of Diabetes
Mellitus

b. Persons with Non-retinal Ocular Complications

1. Basis for Treatment

reatment recommendations depend upon the

nature and severity of the patients ocular
condition and desired visual outcome. Treatment
decisions should reflect the patients preferences and
values. Appendix Figure 1 presents a flowchart for
the management of the patient with undiagnosed
diabetes. Appendix Figure 2 presents a flowchart
outlining the optometric management of the patient
diagnosed with diabetes.
a. Persons with Undiagnosed Diabetes Mellitus
Patients suspected of having diabetes need to be

33

Management of non-retinal ocular complications

of diabetes should be consistent with current
recommendations of care for each condition.
Although a comprehensive discussion of these
therapy regimens is beyond the scope of this
Guideline, Table 5 briefly reviews current clinical
practice for management of common non-retinal
ocular and visual complications.
ACTION: Treatment protocols for persons
with non-retinal ocular and visual complications
should follow current recommendations for
care, and include education on the subject and
recommendations for follow-up visits.

Table 5
Management of Non-retinal Ocular Complications of Diabetes
Category

Ocular /Visual Complications Management*

Functional

Loss of visual acuity

Assess visual acuity as recommended in the Optometric

Clinical Practice Guideline on Adult Eye and Vision
Examination, Pediatric Eye and Vision Examination, or Care of
the Patient with Visual Impairment.

Refractive error changes

Assess refractive error, distance and near and pinhole acuity

as recommended in the Optometric Clinical Practice
Guidelines on Care of the Patient with Myopia and Care of
the Patient with Hyperopia.
Change in spectacle or contact lenses prescription, as
indicated by the patients visual requirements, with special
attention to the persons level of glycemic control.
Counsel patients about variable refractive status due to
fluctuations in blood glucose.

Functional

Changes in color vision

Perform color vision assessment that is sensitive to acquired

(i.e., generally blue/yellow) color vision loss.

Changes in visual fields

Assess visual field changes and manage as recommended in

the Optometric Clinical Practice Guideline on Care of the
Patient with Visual Impairment.
Rule out other causes of visual field changes.

Eye
movement
anomalies

Cranial nerve palsies

Pupils

Sluggish pupillary reflexes

Assess multiple diagnostic positions of gaze; tests of smooth

pursuits (versions and ductions), and saccades.
Rule out other cranial nerve palsies or other etiologies.

Rule out optic neuropathy and other neurological etiologies.

Afferent pupillary defects

Conjunctiva

Bulbar microaneurysms

Monitor

34

Table 5 (continued)
Category

Ocular /Visual Complications Management*

Tear film

Dry eye syndrome

Recommend use of artificial tears, ocular lubricants, and

other dry eye management techniques as recommended in
the Optometric Clinical Practice Guideline on Care of the
Patient with Ocular Surface Disease.
Monitor for corneal complications.

Cornea

Reduced corneal sensitivity

Monitor for abrasions, keratitis, or ulcerations.

Monitor contact lens wear as recommended in the
Optometric Clinical Practice Guideline on Care of the
Patient with Contact Lenses.

Basement membrane anomalies Recommend lubricating drops/artificial tears.

Recurrent corneal erosions

Prescribe sodium chloride solution/ointment or ocular surface

lubricant.
Bandage contact lenses or patching, as necessary.

Iris

Rubeosis iridis
(neovascularization on the iris)

Gonioscopy to rule out anterior chamber angle involvement

and neovascular glaucoma.
Dilated retinal examination to evaluate proliferative diabetic
retinopathy.
Refer to an ophthalmologist experienced in the management
of diabetic retinal disease for possible panretinal
photocoagulation and/or anti-VEGF agents.

Eyelids

Ptosis

Determine etiology (neurologic, mechanical, immunological).

35

Table 5 (continued)
Category

Ocular /Visual Complications Management*

Lens

Cataracts

Assess and monitor degree of lens opacification.

Refraction to obtain best visual acuity. If functional deficits
remain, manage as recommended in the Optometric Clinical
Practice Guideline on Care of the Patient with Visual
Impairment.
Surgery may be indicated, if adequate visualization of the
retina is no longer possible or if visual acuity is decreased
secondary to the cataract.
Refer to Optometric Clinical Practice Guideline on Care of
the Adult Patient with Cataract for more information.

Vitreous

Optic Disc

Premature syneresis/degeneration Dilated retinal examination.

Hemorrhage

Ultrasound, if retinal view is obscured.

Detachment

Consultation with an ophthalmologist experienced in the

management of diabetic retinal disease.

Papillopathy

Management of diabetic papillopathy or ischemic optic

neuropathy may require consultation with a neuroophthalmologist or neurologist to rule out all other potential
etiologies.

Ischemic optic neuropathy

* Communication with the patients health care provider regarding ocular and visual findings, and patient
education are an integral part of management for all conditions.
ACTION: As part of the proper management of
diabetes, the optometrist should make referrals
for concurrent care when indicated.

The Diabetes Control and Complications Trial

3,60,61
and its extended
(DCCT, 19831993)
follow-up, the Epidemiology of Diabetes
Interventions and Complications trial (EDIC,
62,63
1994-present)

c. Persons with Retinal Complications

Major clinical trials provide the scientific basis for
clinical management of diabetic retinopathy:

Diabetic Retinopathy Clinical Research

Network Clinical Trials (DRCR.net,
64-71
2003-present)

The Diabetic Retinopathy Study (DRS,

15-27
19711975)

These studies have guided the current treatment

and management of diabetic retinal disease.
The DRS and ETDRS established the efficacy
and appropriate timing for panretinal laser
photocoagulation to prevent severe vision loss
from diabetic retinopathy. The development of

The Early Treatment Diabetic Retinopathy

28-50
Study (ETDRS, 19791990)
The United Kingdom Prospective Diabetes
56-59
Study (UKPDS, 19771998)

36

endolaser photocoagulation and small gauge

vitrectomy have made the results of the DRVS
less applicable.

a. Laser Photocoagulation

The DCCT and UKPDS established the benefits of

intensive control of blood glucose levels to reduce
the risks of onset and progression of retinal
complications of diabetes in type 1 and type 2
patients, respectively.

Panretinal or scatter photocoagulation (PRP),

in which approximately 1200-2400 laser burns
are scattered throughout the retina, sparing
the macula, is the current standard of care for
the treatment of high-risk PDR. PRP may also
be considered in eyes approaching high-risk
177
PDR. (A/A)

One of the most important contributions

that arose from the DRS and ETDRS was
standardized classification of the varying levels of
diabetic retinopathy based on the modified and
extended Airlie House classification of diabetic
38,40
retinopathy.
This modification formed the
basis of an overall diabetic retinopathy severity
38
scale that ranges from the absence of diabetic
retinopathy to advanced PDR with VH.

While the benefits of PRP are notable in patients

with proliferative retinopathy, PRP is not indicated
177
for DME. (A/A) The presence of DME requires
more frequent evaluation, consultation with an eye
care provider experienced in the management of
diabetic retinal complications and in the presence
of center-involved diabetic macular edema, focal/
grid laser photocoagulation or a regimen of
intravitreal anti-VEGF treatment.

To simplify the classification of diabetic retinopathy

and diabetic macular edema, and to standardize
communication between health care providers,
a Consensus Panel developed an International
Classification of Diabetic Retinopathy and Diabetic
176
Macular Edema Severity Scale (see Appendix
Table 1).

In eyes receiving focal/grid laser for DME and

PRP, the addition of intravitreal triamcinolone
injection or intravitreal ranibizumab injections
is associated with improved visual acuity and
69
decreased macular edema. (A/A) Coexisting
center-involved DME and PDR may be treated
with combined PRP, focal/grid laser and intravitreal
injections.

This simplified classification scale provides a

practical and valid method of grading the severity
of diabetic retinopathy that is appropriate in most
eye care settings and provides a useful scale for
clinicians to use in assessing risk for vision loss.
Retinal specialists typically are familiar with the
ETDRS-derived classification system and continue
to use ETDRS levels.

Complications and side effects of PRP include

visual field constriction, night blindness, color
vision changes, decreased accommodation,
scotoma, anisocoria, glaucoma and traction retinal
detachment. There is evidence to suggest that in
patients with center-involved macular edema, PRP
may worsen retinal thickening in some cases.
In eyes without center-involved macular edema,
the risk for significant worsening of the edema
66
following PRP is low. (B/B)

2. Treatment of Retinal Complications

The current treatment options for diabetic retinopathy
and DME include careful retinal examination and
follow-up, timely laser photocoagulation, monitored
regimens of intravitreal injections (anti-VEGF) for
diabetic macular edema and appropriate use of
vitrectomy surgery in clearing vitreous hemorrhage,
removing fibrous tissue and relieving tractional retinal
detachment.

Non-proliferative Diabetic Retinopathy

While PRP is effective at reducing the risk of
severe vision loss in patients with PDR, it may
also be considered for severe NPDR. Patients
with severe NPDR or worse will invariably require
178
laser photocoagulation. (B/B) However, PRP is

37

not indicated for patients with mild or moderate

37
NPDR. (A/A)

The management of patients following laser

treatment needs to be coordinated with the
recommendations of an eye care provider
experienced in the management of diabetic eye
diseases due to the high rate of patients that may
subsequently need laser or surgical intervention.
Long-term follow-up of the ETDRS patients over a
median of 16.7 years has shown that in patients
who have received PRP, more than 60 percent
will require laser treatment of DME and
178
17 percent will require vitrectomy. (B/B)

Panretinal laser photocoagulation can exacerbate

DME in some individuals. Since the relative
risk of vision loss in patients without high-risk
characteristics is low, treatment of CSME or
center-involved DME should be considered before
177
panretinal laser photocoagulation is used. (A/A)
ACTION: Panretinal photocoagulation may be
considered in patients with severe or very severe
non-proliferative diabetic retinopathy (NPDR), or
early proliferative diabetic retinopathy (PDR) with
a high risk of progression (e.g. pregnancy, poor
glycemic control, inability to follow-up, initiation
of intensive glycemic control, impending ocular
surgery, renal impairment and rapid progression
177
of retinopathy). [Evidence Strength: A,
Recommendation: A]

Patients receiving PRP for PDR have similar risks

of development of macular edema, whether the
PRP is delivered in a single session or 4 sessions
66
over 12 weeks. (B/B)
Patients with diabetic retinopathy who require
laser photocoagulation need aggressive followup examinations and intervention to achieve
good visual acuity outcomes and because of a
178
dramatically increased risk of mortality. (B/B)

Proliferative Diabetic Retinopathy

Proliferative diabetic retinopathy is marked by new
vessel growth on the optic disc or elsewhere
on the retina, VH, pre-retinal hemorrhage, or the
proliferation of fibrous tissue on the optic disc or
elsewhere on the retina. Scatter (panretinal) laser
photocoagulation is generally indicated when highrisk proliferative diabetic retinopathy is present.

ACTION: Following successful treatment with

panretinal photocoagulation (PRP), patients should
be re-examined every 2 to 4 months. The followup interval may be extended based on disease
severity and stability.
Diabetic Macular Edema

ACTION: Patients with high-risk proliferative

diabetic retinopathy (PDR) should receive
referral to an ophthalmologist experienced in
the management of diabetic retinal disease for
prompt scatter (panretinal) photocoagulation.
37
[Evidence Strength: A, Recommendation: A],
178
[Evidence Strength: B, Recommendation: B]

The management of patients with DME has

evolved substantially in recent years. The
ETDRS established the efficacy of focal/grid
28
photocoagulation for the treatment of CSME. (A/A)
The DRCR.net demonstrated that center-involved
DME, with vision reduced to 20/32 or worse, is
best treated with intravitreal anti-VEGF followed
by either prompt or deferred (up to six months)
focal laser photocoagulation. Treatment is generally
recommended for all eyes with CSME. Frequent
follow-up is needed to determine whether
additional treatment is necessary for persistent
28
CSME. (A/A)

ACTION: Eyes in which PDR has not advanced

to the high-risk stage should also be referred for
consultation with an ophthalmologist experienced
in the management of diabetic retinal disease.
37
[Evidence Strength: A, Recommendation: A],
178
[Evidence Strength: B, Recommendation: B]

ACTION: Following focal photocoagulation for DME,

re-examination should be scheduled in 3 to 4 months.

38

In the ETDRS, focal/grid laser treatment of CSME

substantially reduced the risk of moderate visual
loss, increased the chance of visual improvement,
decreased the frequency of persistent macular
edema, and caused only minor visual field losses.
However, despite focal/grid laser treatment,
16 percent of patients may continue to experience
vision loss. Recent data demonstrated that
a regimen of sequential intravitreal anti-VEGF
injections is more effective than focal/grid laser
alone in the treatment of center-involved
67
179
DME. (A/A), (A/B)
Eyes with center-involved DME and visual
impairment should be considered for possible
initiation of a regimen of anti-VEGF injections with
prompt or deferred focal/grid laser. An average
of 8 to 9 intravitreal injections may be needed
in the first year of treatment. This number may
be reduced to 2 to 3 and 1 to 2 injections
in the second and third years of follow-up,
respectively. However, the full benefit of macular
laser treatment or intravitreal injection may not be
180
manifest until the second year of treatment. (A/A)

Focal/grid laser is typically not indicated in eyes

without CSME. Such patients should be reexamined within 4 to 6 months. Follow-up for
proper management of the retinopathy can be
28,29,31,33
Patients judged
more frequent, if required.
to be at high short-term risk for progression of
DME should be followed in consultation with an
ophthalmologist experienced in the management of
diabetic retinal disease.
ACTION: Individuals with diabetic macular edema
(DME), but without clinically significant macular
edema (CSME), should be re-examined at
4- to 6-month intervals. Once CSME develops,
treatment with focal laser photocoagulation or
intravitreal anti-VEGF injection is indicated.177
[Evidence Strength: A, Recommendation: A)
b. Vitrectomy
Vitrectomy is used for treating vitreous hemorrhage
and PDR with non-clearing vitreous hemorrhage or
fibrosis, areas of traction threatening the macula
and persistent DME with vitreous traction. Less
frequently, vitrectomy may be used for DME that
is nonresponsive to focal laser treatment.

ACTION: Patients with center-involved diabetic

macular edema (DME) should be referred to an
ophthalmologist experienced in the management
of diabetic retinal disease for possible treatment.

Vitrectomy can result in a reduction in macular

68
thickening (C/B) and can improve visual acuity in
DME when the pre-operative acuity is < 20/80
and there is an epiretinal membrane or vitreo181
retinal adhesion. (C/B)

The Ranibizumab Injection in Subjects with

Clinically Significant Macular Edema with Center
Involvement Secondary to Diabetes Mellitus (RISE
and RIDE) studies demonstrated that ranibizumab
significantly reverses vision loss from DME.
In addition, patients treated with ranibizumab
experienced fewer complications such as vitreous
hemorrhage and fewer developed PDR or
179
underwent panretinal photocoagulation. (A/B)
The presence or absence of CSME is the most
important factor in determining when people with
maculopathy and mild to moderate NPDR should
be treated. Before development of CSME, the risk
of vision loss is very low and there is no evidence
that early focal laser macular photocoagulation
177
provides any additional benefit. (A/A)

39

While the use of vitreo-retinal procedures for the

management of the late complications of PDR
remains a common treatment, for many patients
182
the visual results are guarded. (B/B) Early
vitrectomy appears more effective than deferred
vitrectomy at improving visual acuity in people
with recent severe vitreous hemorrhage. The trend
to operate in patients earlier and on those with
better vision has also been associated with better
182
visual outcomes. (B/B)

ACTION: Eyes with vitreous hemorrhage (VH),

traction retinal detachment (TRD), macular
traction or an epiretinal membrane should be
referred to an ophthalmologist experienced in
the management of diabetic retinal disease for
evaluation for possible vitrectomy.

grid photocoagulation is more effective with

respect to both visual acuity and OCT-measured
retinal thickening and has fewer side effects
than intravitreal triamcinolone in most patients
64
with DME. (A/A) When combined with focal/
grid laser treatment, the benefit of IVTA injections
is comparable to anti-VEGF injections only in
67
pseudophakic eyes. (A/A) Triamcinolone plus
prompt grid photocoagulation is effective in
67
pseudophakic eyes. (A/A) There is no evidence
that lower doses of intravitreal triamcinolone
acetonide than the standard 4 mg dose have
more benefits or fewer adverse effects.

Potential complications of vitrectomy include

neovascular glaucoma, retinal detachment, vitreous
hemorrhage, retinal tear formation, cataract and
68
177
182
endophthalmitis. (C/B), (A/A), (B/B) Glaucoma
is more likely to occur in people with associated
177
preoperative retinal detachment. (A/A)
c. Intraocular Steroids

Intravitreal steroid implants may avoid the

complications resulting from repeat injections of
IVTA and may have a more sustained effect.
However, they also increase the risk of cataract
184
progression and elevated IOP. (B/B)

The pathogenesis of diabetic retinopathy and

DME is multifactorial, involving both angiogenic
and inflammatory pathways. The anti-inflammatory
and anti-angiogenic properties of intraocular
corticosteroids may provide benefit in the
treatment of PDR and DME. However, the exact
role of intraocular steroids in the treatment for
183
PDR and DME remains to be fully established.

d. Vascular Endothelial Growth Factor Inhibitors

The use of anti-VEGF agents has substantially
changed the treatment of DME. Intraocular
injection of anti-VEGF agents is considered to
be the standard of care in patients with centerinvolved DME and best corrected visual acuity
64
of 20/32 or worse. (A/A) Repeated intravitreal
administration of anti-VEGF agents has been
shown to be more effective than conventional
67
focal/grid laser alone in the treatment of DME. (A/A)

The use of intravitreal triamcinolone acetonide

(IVTA) injections and intraocular corticosteroid
sustained release drug delivery systems for the
treatment of DME has been shown effective in
decreasing macular thickness and improving visual
177
184
185
acuity. (A/A), (B/B), (B/B)
The use of 4 mg intravitreal triamcinolone
acetonide shows a beneficial effect for DME,
but repeated injections are needed every 3 to 4
months to maintain the benefit, which decreases
178
to baseline by 6 months. (B/B) The use of
IVTA has been associated with a substantial
risk of adverse events. In particular, the risk of
elevated intraocular pressure and the rates of
visually significant cataracts were substantially
higher compared to eyes receiving focal/grid laser
64
treatment. (A/A)

ACTION: The current standard of care for

treatment of center-involved diabetic macular
edema (DME) in persons with best corrected
visual acuity of 20/32 or worse, is antiVEGF injections.64,67 [Evidence Strength: A,
Recommendation: A]
The combination of anti-VEGF injection
of ranibizumab plus prompt or deferred
photocoagulation provides better visual outcomes
67
than grid photocoagulation alone. (A/A)

IVTA injections given as monotherapy for DME

have been shown to result in inferior outcomes
compared to focal/grid laser treatment. Focal/

Anti-VEGF treatment for CSME combined

with either prompt or delayed focal laser
photocoagulation provides improved visual acuity

40

outcomes compared to prompt laser treatment

71
alone, through at least two years of follow-up. (A/B).
Deferral of focal/grid laser following anti-VEGF
treatment for at least 24 weeks may achieve
better visual outcomes compared to eyes receiving
prompt focal/grid laser treatment, since nearly 50
71
percent of eyes do not need laser treatment. (A/B)
Focal/grid laser at the initiation of intravitreal
ranibizumab is no better, and possibly worse, than
deferring laser for at least 24 weeks in eyes with
DME involving the fovea with vision impairment.
Intravitreal ranibizumab injections with or without
prompt laser at 1 year are more effective
compared to prompt laser alone for the treatment
of DME involving the central macula with visual
impairment. Furthermore, focal/grid laser at the
initiation of intravitreal ranibizumab is no better,
and is possibly worse than, deferring laser for at
least 24 weeks in these eyes. The beneficial effect
has been shown to continue to at least 3 years
with a reduction in the number of injections at
71
years 2 and 3. (A/B)
Following ischemic events, VEGF has a pivotal role
in promoting collateral vessel formation, which is
particularly important in persons with diabetes who
are at increased risk of having cardiovascular and
peripheral vascular events. Therefore, long-term
systemic VEGF inhibition can result in increased
risk of ischemic and thromboembolic events. The
risk of such events with systemic administration
was found to be 5 percent. However, these
patients received anti-VEGF intravenous doses that
were several hundredfold what is typically given
intravitreally. Commonly administered intravitreal
doses of anti-VEGF therapy are approximately
1/400 or less of the usual systemic dose.
Nevertheless, the possibility of systemic adverse
186
side effects exists.
Currently available anti-VEGF agents:
Pegaptanib (Macugen) is FDA approved for
the treatment of wet age-related macular
degeneration and is used off-label for other

41

indications, including DME.

Ranibizumab (Lucentis) is FDA approved
for treatment of wet age-related macular
degeneration, retinal vein occlusion and DME.
The dose for DME is 0.3 mg, compared to
the 0.5 mg dose for wet age-related macular
degeneration and retinal vein occlusion.
Aflibercept (Eyelea) is FDA approved for
the treatment of wet age-related macular
degeneration and central retinal vein
occlusion. The dose is 2 mg in 0.05 mL
given intravitreally.
Bevacizumab (Avastin) is approved for
treatment of cancer and its systemic use is
known to be associated with an increased
risk of stroke. It is unknown if a substantially
smaller dose, when used intravitreally, has
177
any significant systemic toxicity. (A/A) It
is used off-label for the treatment of DME.
Intravitreal bevacizumab results in superior
visual outcomes compared to focal/grid laser
180
treatment over 2 years. (A/A)
Ocular adverse events resulting from the
intravitreal injection itself include endophthalmitis,
ocular inflammation, retinal detachment, vitreous
hemorrhage and traumatic cataract. Data from
more than 2,009 injections administered in clinical
trials employing the same standardized procedure
for the preparation and intravitreal injection using
preservative-free triamcinolone in pre-filled syringes
has reported only one case of endophthalmitis
187
(0.05 percent).
Multiple studies suggest that there are significant
benefits from anti-VEGF treatment for DME in
terms of visual acuity improvement and decrease
in retinal edema. Two- and three-year data on
safety and efficacy of anti-VEGF therapies for
DME have reported significantly better outcomes
compared to focal/grid laser while maintaining
limited adverse events. However, focal/grid laser
treatment still remains an effective treatment
modality in patients with noncenter involved DME

or in patients unable to tolerate intravitreal injection

modality in patients with noncenter involved DME
(e.g. those with noncenter involved CSME or
vision better than 20/32) or in patients unable to
tolerate intravitreal injections.
3. Telehealth Programs
Ocular telehealth programs can be an integral
component of primary care for patients with diabetes.
Telehealth programs can increase access and
adherence to demonstrated standards of care among
188
individuals with diabetes. Studies across multiple
populations demonstrate that the prevalence of
blindness and visual impairment among patients with
diabetes is lowest among populations with a national
telehealth program that provides retinal evaluations for
189-191
all patients with diabetes.
The implementation of national coverage of universal
retinal evaluation for all patients with diabetes
mellitus has been shown to reduce the incidence
of blindness among patients with diabetes by as
192,193
much as 95 percent.
Telehealth programs have
been largely used in these initiatives and rely on
the digital capture and transmission of standardized
ocular images and patient health information for
interpretation and evaluation by trained observers
who can generate a treatment and care plan. These
programs may substantially assist in the accurate
detection and evaluation of individuals at risk for or
188
having sight-threatening diabetic retinopathy.
Ocular telehealth programs for diabetic retinopathy
have the potential to preserve vision and prevent
vision loss by increasing access to evaluation,
educating patients and promoting appropriate followup and treatment. Telehealth has the potential to
deliver economical, high quality eye care locally,
194
nationally and internationally. (B/A) These programs
integrate appropriately validated digital retinal imaging
systems with standardized methods of image
acquisition and review that provide high levels of
sensitivity and specificity, and agreement with dilated
standard photography or clinical examination for the
detection and assessment of the severity of diabetic
188
retinal disease when implemented appropriately.

However, telehealth-based retinal evaluations are not

a substitute for a comprehensive eye examination by
an eye care professional.
4. Patient Education
The vast majority of persons with diabetes will
develop diabetic retinopathy at some point during
the course of the disease. Therefore, it is important
for them to learn about the disease process and the
risks for developing ocular complications of diabetes
that may result in vision loss. Individuals need to be
aware that retinopathy may exist even when vision is
good and in the absence of any symptoms.
Persons should be encouraged to report all ocular
symptoms (e.g. blurred vision, flashes and floaters).
Optometrists should help patients understand that
timely follow-up examinations and management are
critical for early diagnosis and intervention, when
indicated, to reduce the risk of vision loss from
diabetic retinopathy. Individuals should also be
informed about their higher risk for other non-retinal
ocular complications, such as cataracts, neovascular
glaucoma and open angle glaucoma, and informed
about available optometric vision rehabilitation care
to address loss of visual function. Proper monitoring
and timely treatment can result in subsequent saving
of sight for persons with diabetes mellitus.
ACTION: Persons should be educated about
the ocular signs and symptoms of diabetic
retinopathy and other non-retinal complications
of diabetes, and encouraged to comply with
recommendations for follow-up eye examinations
and care.
Individuals should also be encouraged to participate
in diabetes education programs. Despite substantial
improvement during the past decade, achieving
the diabetes ABCs recommendations (A1C, blood
pressure, cholesterol and smoking cessation) remain
suboptimal among adults, particularly in some
minority groups (Mexican Americans and nonHispanic Blacks). Substantial opportunity exists to
further improve diabetes control and, thus, to reduce
195
diabetes-related morbidity and mortality.

42

developing ocular and other medical complications.

Specific emphasis should be placed on the benefit
of reduction in elevated A1C in lowering the risk of
damage. A one percent rise in A1C (e.g. from 7 to
8 percent) increases the risk of progression of nonproliferative retinopathy by 44 percent over a 10-year
period. For the individual with proliferative retinopathy,
the same one percent increase in A1C results in 145
60,92,203
percent progression over 10 years.

In addition, there is a clear need to increase the

frequency of smoking cessation counseling for
patients with diabetes, given the strong association
196
between smoking and diabetes complications.
ACTION: Individuals should be advised of
the risks of smoking related to diabetes and
encouraged to quit smoking and/or seek smoking
cessation assistance.
Diabetes education programs should not just provide
information, but involve the person in making
well-informed choices. Research has shown that
individuals with diabetes, who actively participate
in an empowerment-based approach to diabetes
education, are substantially more likely to accurately
recall the meaning of the diabetes ABCs, recall their
own personal ABCs, and know their clinical target
197
ABCs, than those receiving traditional education. (B/B)
Intensive diabetes education, defined as adoption
of behaviors that allow for active engagement in
diabetes self-management, is more effective in
lifestyle behavior modification and glycemic control
in newly or recently diagnosed individuals with
diabetes compared to patients with a longer duration
198
of diabetes. (C/B) A structured, group-based
educational program focusing on self-management
can further improve A1C levels, even in patients
199
who are well controlled. (C/B) In addition, the use
of culturally appropriate diabetes health education
programs for socio-economically disadvantaged ethnic
groups appears to be effective in improving glycemic
control and increasing knowledge of diabetes and
200
healthy lifestyles, at least in the short term. (B/B)
Improved A1C control is associated with health
care providers who more effectively communicate
201
with persons who have type 2 diabetes. (C/B) In
addition, providing them with personalized clinical
information during a consultation can increase their
involvement and make them more likely to take the
202
lead in discussing aspects of their diabetes care. (B/B)
Persons should be informed of the relationship
between the level of glycemic control and the risk of

ACTION: Individuals should be educated about

the long-term benefits of glucose control in
saving sight, based on their individual medically
appropriate A1C target.
Those with diabetic retinopathy have a measurable
decline in health-related quality of life early in the
disease process. This decline is much greater and
more rapid in persons with bilateral moderately
severe NPDR or worse, compared with those with
no diabetic retinopathy or less severe diabetic
204
retinopathy. (C/B) Therefore, it is important to also
consider psychological and emotional support for
patients with diabetes mellitus, especially those with
longer diabetes duration or diabetes complications,
to maximize the effectiveness of diabetes education.
Diabetes burn-out or diabetes-related stress
198
influences patient self-care behaviors. (C/B) Special
care is also indicated in counseling elderly patients.
Their risks and benefits may be different; therefore,
as with all persons, the discussion and instruction
205
should be individualized.
The use of a team approach to providing supportive
care for people with diabetes can help reduce
risk factors for type 2 diabetes, improve diabetes
management and lower the risk for chronic
206
complications. (C/B)
It is helpful to advise individuals about organizations
that provide resources and support for people with
diabetes. (A list of organizations is available from the
AOA Clinical Resources Group.)
5. Prognosis and Follow-Up
Disability and premature death are not inevitable

43

consequences of diabetes. Lifestyle and behavioral

modification, and pharmacotherapy, can delay
progression to type 2 diabetes among persons
86
with prediabetes. (A/B) Physical activity, dietary
interventions, and, when needed, medications can
also help control the effects of diabetes.
All persons with diabetes mellitus are at risk for
the development of ocular-related complications.
Adherence to treatment recommendations to
maintain optimal control of blood glucose levels is
a substantial factor in slowing the development and
progression of complications of diabetes.
Recent studies indicate that the rates of progression
to PDR and severe vision loss are substantially lower,
especially in individuals with type 1 diabetes, than
reported thirty or more years ago. These findings
may be due to improvements in the management
of risk factors (hyperglycemia, hypertension and
hyperlipidema) and overall diabetes care, along with
115
earlier identification of diabetes.
Regular retinal examinations can identify
diabetic retinopathy before it causes visual loss.
Epidemiological studies have shown that the major
predictors of retinopathy progression are the
presence and severity of retinopathy at the time of
207
the patients initial eye examination.
The follow-up examination of persons with diabetic
retinopathy should be scheduled in accordance with
recommendations in this Guideline. Proper diagnosis
is crucial because misdiagnosis by just one level
underestimates a patients risk of developing PDR in
1 year by 50 percent or more.
Laser photocoagulation greatly improves the
prognosis for maintaining useful vision. Scatter
(panretinal) laser photocoagulation reduces the risk of
severe vision loss (best visual acuity < 5/200) to less
than 2 percent per patient. Anti-VEGF injections for
center-involved diabetic macular edema reduce the
risk of moderate visual loss to less than 5 percent,
with nearly 50 percent of patients gaining 10 or
more letters of visual acuity.

Appropriate communication with the patients primary

care physician (as with any referral consultant) is
critical for proper coordination of the patients care.
Due to the nature of diabetes, a multidisciplinary
approach to the management of individuals with
diabetes is essential. All health care personnel
involved with the individuals care should be aware
of his or her overall medical status. Written letters or
reports are useful in accomplishing this task. These
letters also provide permanent documentation for the
patients record.

B. Management of Systemic
Complications and Comorbidities
of Diabetes Mellitus
The management of persons with diabetes
mellitus includes individualized glucose targets
and lifestyle modifications. The individuals age,
weight, comorbidities, race/ethnicity, and physiologic
differences need to be considered in determining
78,208
treatment.
(C/B)
Some individuals with type 2 diabetes can achieve
adequate glycemic control with weight reduction,
exercise and/or oral glucose-lowering agents and do
not require insulin. Others, who have only limited
residual insulin secretion, often require insulin for
adequate glycemic control. Individuals with type 1
diabetes, who have extensive beta-cell destruction
and therefore no residual insulin secretion, require
6
insulin for survival.
1. Glycemic Control
While previous standards for diabetes management
emphasized the need to maintain glucose levels
as near to normal as safely possible, current
standards emphasizes individualization. According to
the American Diabetes Association, reducing A1C
levels to less than 7 percent has been shown to
reduce microvascular complications; therefore, it is a
78
reasonable goal for many nonpregnant adults.
For individuals with short duration of diabetes, long
life expectancy and no significant cardiovascular
disease, a more stringent A1C goal (<6.5 percent)

44

may be reasonable, if it can be achieved without

significant hypoglycemia. For individuals with
a history of severe hypoglycemia, limited life
expectancy, advanced microvascular or macrovascular
complications, or extensive co-morbid conditions, a
less stringent A1C goal, such as <8 percent, may be
78
appropriate.
ACTION: The glycemic goal for persons
with diabetes should be individualized, taking
into consideration their risk of hypoglycemia,
anticipated life expectancy, duration of disease
and co-morbid conditions.78
A recent consensus statement for managing diabetes
during pregnancy recommends that pregnant women
with pre-existing type 1 or type 2 diabetes who
become pregnant maintain an A1C goal of <6
percent throughout pregnancy, if it can be achieved
209
without excessive hypoglycemia.
In persons with type 2 diabetes mellitus, intensive
glucose control may reduce microvascular disease,
210
retinopathy, nephropathy, cataract and neuropathy,
(B/B) non-fatal myocardial infarction and lower
extremity amputation. However, in light of recent
211
212
213
trials such as ACCORD ADVANCE and VADT,
cardiovascular disease is less clearly impacted by the
degree of glycemic control.
Intensive glucose control in individuals with type 2
diabetes and established cardiovascular disease or
additional cardiovascular risk factors (hypertension,
dyslipidemia, smoking) should not be recommended
211
due to the increased risk for death. (A/B)

some diabetes related complications, it also increases

the relative risk of severe hypoglycemia by 30
214
percent. (A/B) In addition, the added benefits of
a 1 percent reduction in A1C (e.g. 8 to 7 percent)
210
diminish with age. (B/B)
Hypoglycemia is defined as a plasma glucose level
below 70 mg/dL, which is confirmed when symptoms
are relieved after eating. The classic symptoms of
hypoglycemia are hunger, shakiness, nervousness,
215
sweating, or weakness. While hypoglycemia is
more common in type 1 diabetes, the incidence is
also high in individuals with type 2 diabetes who use
insulin or secretagogues, particularly those with longer
216
duration of diabetes.
It is common for individuals with diabetes to
experience symptoms suggestive of hypoglycemia
even with above-normal glucose levels, if they have
had chronically elevated blood glucose. However,
as persons experience more frequent low blood
glucose, they gradually lose the classic symptoms
of hypoglycemia due to defective glucose counter
216
regulation (hypoglycemia unawareness). To help
identify persons experiencing hypoglycemia, the
staff should be alert for neuroglycopenic symptoms
such as slow cognitive response, light-headedness,
sleepiness, confusion, difficulty speaking, and anxiety.
It may be prudent for optometrists offices to
maintain a blood glucose meter and single use lancet
devices for confirming hypoglycemia and its resolution
where state laws permit.
The treatment of a hypoglycemic episode may
include:217

In addition, intensive control has been shown to

have no significant impact on the risk for nonfatal
heart attack or stroke, as well as death from
cardiovascular causes, and cannot be recommended
as a strategy for reducing such events in individuals
212
with type 2 diabetes. (A/A) Intensive control (A1C
of 6.5 percent versus 7.3 percent) also showed no
benefit for reducing the risk of new or worsening
212
retinopathy over 5 years. (A/A)

1. Check blood glucose to confirm hypoglycemia

(blood glucose <70 mg/dL).
2. If patient is conscious, give 15 g of simple
carbohydrates orally as immediate treatment.
Options include 4 oz of fruit juice, 5 to 6 oz
regular soda, 1 tablespoon of table sugar or
honey, 7 to 8 Lifesaver candies, 3 tablespoons
of jelly, 2 tablespoons of raisins, or 4 to
5 glucose tablets. If initial blood glucose is
less than 50 mg/dL, give 30 g of simple

While achieving tight glycemic control may reduce

45

carbohydrates.
3. Re-check blood glucose after 1015 minutes.
If blood glucose is less than 70 mg/dL repeat
the treatment (step 2) until blood glucose returns
to at least 90 mg/dL.
4. Follow with a meal or snack such as
6 saltine crackers, 3 graham cracker squares
or 1/2 peanut butter sandwich. Further glucose
monitoring may be necessary.
5. Activate 911, if patient is unconscious. Inject
glucagon intramuscularly, if it is available in the
office.
6. When the person is alert enough to swallow,
give fruit, fruit juice or sugar-sweetened soda
immediately and follow steps 2 to 4.
ACTION: Optometrists should have a rapid-acting
carbohydrate (e.g. glucose gel or tablets, sugarsweetened beverage or fruit juice) in their office
for use with diabetes patients who experience
acute hypoglycemia during an eye examination.

retinopathy in patients with type 2 diabetes mellitus,

although the ADVANCE study reported that a
consistent trend toward a benefit was observed.
However, the Wisconsin Epidemiologic Study of
Diabetic Retinopathy showed that elevated blood
pressure and A1C are directly related to the
development of DME and CSME in type 1 diabetes
mellitus, and persons with elevated blood pressure
need to be evaluated earlier for DME and CSME and
111
treated more aggressively. (B/A)
3. Lipid-Lowering Treatment
Individuals with type 2 diabetes mellitus have an
increased prevalence of lipid abnormalities, which
contributes to a higher risk for CVD. Lowering
LDL cholesterol to <100 mg/dL is a recommended
goal for individuals without overt CVD. However,
in individuals with overt CVD, LDL <70 mg/dL is
78
recommended. This level may be achieved through
lifestyle modifications (e.g. reduction in saturated
fats and cholesterol, weight loss, increased physical
78
activity), along with statin therapy.
ACTION: The majority of persons with diabetes
are at risk of coronary heart disease and can
benefit from reducing low-density lipoprotein
(LDL) cholesterol levels to the currently
220
recommended targets. [Evidence Strength: B,
Recommendation: B]

2. Blood Pressure Control

Hypertension is a common comorbidity of diabetes
mellitus and a major risk factor for cardiovascular
disease (CVD) and microvascular complications. Slight
variations in optimum blood pressure for people
with diabetes can be cited in the literature. Blood
pressure of <140/80 mmHg has been recommended
78
for most patients with diabetes. Lower systolic
blood pressure of <130 mmHg may be appropriate
for younger individuals. Treatment may include life
style modifications, (e.g. weight loss, diet changes,
exercise) along with pharmacological agents, when
78
needed.
The impact of blood pressure control on the
progression of diabetic retinopathy is unclear. The
218
ACCORD Eye Study (B/B) and the ADVANCE
219
Retinal Measurements Study (B/B) looked at
intensive blood pressure control versus standard
blood pressure control. The studies did not find
a significant effect on the progression of diabetic

As a preventive approach, persons with

diabetes should be treated as if they have
cardiovascular disease. In the absence of severe
hypertriglyceridemia, therapy targeting HDL cholesterol
or triglycerides lacks the strong evidence base of
statin therapy.78
Statins (e.g. simvastatin, lovastatin, atorvastatin) are
the first choice agents for reducing high cholesterol.
According to the ADA, statin therapy should be
initiated for diabetic patients without regard for
baseline lipid level in those with overt CVD or those
without CVD who are over age 40 and have one or
more other CVD risk factors (family history of CVD,
78
hypertension, smoking or albuminuria).

46

Combination therapy with a statin and other

classes of lipid lowering agents may be used to
further reduce LDL levels; however, this approach
has not been demonstrated to provide additional
78
cardiovascular benefit above statin therapy alone.
There is emerging evidence that normalizing blood
lipid levels may also reduce the risk of retinopathy.
Intensive treatment of dyslipidemia using a
combination of simvastatin and fenofibrate, along with
intensive glucose control, has been shown to slow
the rate of progression of diabetic retinopathy in type
218
2 diabetes mellitus. (B/B) Fenofibrate may also have
a role in reducing the risk of diabetic retinopathy
and its progression independent of its lipid modifying
221
action. (B/B)
4. Cardiovascular Risk Reduction
The major cause of death and complications
in individuals with type 2 diabetes mellitus is
cardiovascular disease. Persons with type 2
diabetes have a substantially increased risk of
cardiovascular disease compared with persons
without diabetes of similar age and need to
208
222
be treated aggressively. (C/B), (B/B)
Successful prevention and treatment of CVD risk
factors have reduced the burden of coronary heart
disease among U.S. adults with diabetes over
223
the past decade. Significant progress has been
achieved when multiple risk factors such as blood
pressure control, lipid management, antiplatelet
agents and smoking cessation are addressed
224
globally.
5. Physical Exercise
Exercise is a vital component for the prevention
and management of type 2 diabetes. The benefits
are greatest when used early in the course of the
225
disease.
Regular exercise has been shown to improve blood
glucose control, reduce cardiovascular risk factors,
contribute to weight loss and improve well-being.
Regular exercise may also help prevent type 2
diabetes in high-risk individuals.

It is recommended that all persons with diabetes

participate in at least 150 minutes per week of
moderate-intensity aerobic exercise, spread over at
least 3-days per week, and unless contraindicated,
78
perform resistance training at least twice per week.
6. Weight Management
Being overweight or obese is associated with
increased risk of developing type 2 diabetes. It
is important for individuals to understand this
association, as well as how to prevent or remedy
excess body weight through dietary modification
and increased physical activity. Among those who
have pre-diabetes or are at high risk for developing
type 2 diabetes, a modest weight reduction of 5 to
7 percent combined with 150 minutes of physical
activities per week significantly reduces the likelihood
89
of developing diabetes.
Very obese adults, who are at high risk for
developing diabetes, can reduce their cardiometabolic
risk with primary care weight management. Modest
weight loss (5 percent to 9.9 percent) during a oneyear period is an appropriate short-term goal for
226
people who are severely obese. (B/B) Behavioral
modification such as medical nutrition therapy and
physical activity are essential elements of weight loss
programs and are especially critical in the weight
78
maintenance phase.
Although bariatric surgery is effective for reducing
weight and may be considered for adults with
BMI 35 kg/m2 and type 2 diabetes, the longterm
benefits, cost-effectiveness and risks of bariatric
78
surgery need to be more rigorously studied.
ACTION: When indicated, overweight individuals
should be referred to a qualified health care
provider for assistance with weight loss.
7. Treatment Modalities
Among adults with either type 1 or type 2 diabetes,
the percentage receiving treatment using one of the
8
following methods is:
Insulin only 12 percent

47

Thiazolodinediones (pioglitazone,
rosiglitazone), which decrease insulin
resistance by enhancing insulin-mediated
glucose disposal by muscle/fat.

Insulin and oral medications 14 percent

Oral medications only 58 percent
No insulin or oral medications 16 percent

Dipeptidyl peptidase (DPP) 4 inhibitors

(sitagliptin, saxagliptin, linagliptin) are another
category of oral medications that prolong the
action of incretin hormones and regulate the
level of insulin produced after a meal.

Specific treatment modalities include:

Medical nutrition therapy - Dietary
recommendations need to take into account
the individuals total daily caloric requirements
and promote weight control to achieve an ideal
body weight. Recommended carbohydrate,
protein and fat intake levels can be determined
227
using ADA Guidelines. If used early in the
disease, nutritional therapy and weight loss may
be sufficient for controlling type 2 diabetes in
many individuals.

Bile acid sequestrant (colesevalem) is a

medication that is a non-absorbed lipid and
glucose lowering resin that binds bile acids in
the digestive track. Its mechanism of action
in reducing glucose levels is unknown.
Dopamine agonist (bromocriptine) works
by modulating hypothalamic dopamine levels
and reducing sympathetic tone, resulting in
reduced postprandial glucose levels.

ACTION: Individuals with diabetes should receive

nutrition and dietary recommendations preferably
provided by a registered dietician who is
knowledgeable about diabetes management.

SGLT2 inhibitor (canagliflozin) lowers blood

glucose by blocking re-absorption of glucose
and increasing its excretion in urine.

Oral medications A variety of classes

of medications are available to treat type 2
228
diabetes. The specific agents are listed in
Table 6:

Amylin agonist (pramlintide) is an injectable

therapy that works by slowing gastric
emptying, promoting satiety in the brain and
inhibiting excessive glucagon secretion. Native
amylin is co-secreted by the B-islet cells.

Biguanides, which block hepatic glucose

production (nocturnal gluconeogenesis), are a
first-line pharmacological agent for treatment
of diabetes.

GLP-1 mimetics/analogs (liraglutide,

exenatide) is an injectable therapy that
works by delaying gastric emptying, centrally
suppressing appetite, stimulating insulin
secretion and suppressing excessive glucagon
secretion. Native GLP-1 is secreted by the
gut.

Sulfonylurea compounds, which stimulate

the pancreas to release more insulin. Their
use also reduces hepatic glucose production
and increases the number of insulin
receptors.
Alpha-glucosidase inhibitors, which block
starch, sucrose and maltose absorption.

Insulin - The many forms of insulin are

classified by how fast they start to work and
how long their effects last. Rapid-acting insulin,
such as lispro, aspart and glulisine, starts
working in 15 minutes and lasts 3 hours.
A rapid-acting insulin allows the individual
to control postprandial hyperglycemia more

Meglitinides (repaglinide, nateglinide) increase

insulin secretion, but their effect typically is
shorter than that of sulfonylureas.

48

effectively. Most patients require some type of

multiple or split dosage regimen to maintain
adequate blood glucose control.
The basal insulins, glargine and detemir, mimic
continuous, endogenous background insulin
secreted by the pancreas and have a slowrelease, long-acting effect to help control
glucose levels throughout the day and night. All
insulins may be administered by subcutaneous
injection. Only short- or rapid-acting insulins are
delivered by continuous subcutaneous insulin
pump infusion.
The use of combination oral therapies and oral
therapies combined with insulin is increasing. A
combination approach enables the individual to obtain
the benefit of synergistic actions of the various
208
medications while reducing adverse effects. (C/B)
Self-Monitoring Glucose
Daily self-monitoring of blood glucose by the
patient with a glucose monitor is a well-accepted
practice. Such monitoring, which is absolutely
necessary for intensive management programs,
78
should be encouraged for all persons with diabetes.
Continuous glucose monitoring systems (CGMS),
which measure interstitial glucose levels, are
increasingly being used by insulin-dependent persons
with diabetes and have been shown to improve
229
glycemic control in several studies.

49

Table 6
Class

Examples

Diabetes Medication
Hypoglycemic
Injectable
potential

A1C reduction

(Used alone)
Biguanides

Metformin

minimal

No

1.5-2%

Sulfonylurea &
glinides

Glyburide

Yes

No

1-2%

Minimal

No

0.5-1%

Glipizide
Glimepiride
Nateglinide
Repaglinide

Alpha-glucosidase
inhibitor

Acarbose

Thiazolidinedione

Rosiglitazone
Pioglitazone

Minimal

No

0.6-1.9%

DPP-IV inhibitor

Sitagliptin

Minimal

No

0.6-0.8%

Miglitol

Linagliptin
Saxagliptin
Bile acid
sequestrant

Colesevelam

Minimal

No

0.5-0.6%

Dopamine agonist

Bromocriptine

Minimal

No

0.6-1.0%

SGLT2-inhibitor

Canagliflozin

Minimal

No

0.9-1.1%

GLP-1 agonist/
analog

Exenatide

Minimal

Yes

0.8-1.2%

Yes (when used

with insulin)

Yes

0.6%

Exenatide LAR
Liraglutide

Amylin analog

Pramlintide

50

C. Management of persons with

Visual Impairment
Individuals with diabetes are at increased risk of
chronic vision loss, subsequent functional impairment,
and resultant disability. Common visual impairments
associated with diabetic retinopathy include:
Reduced central visual acuity affecting near,
intermediate, and distance visual function

Persons with diabetes-related vision loss should be

evaluated to determine their potential to benefit from
comprehensive vision rehabilitation. This process
provides the only currently available treatment options
for those with chronic vision loss. Vision rehabilitation*
can help individuals with vision loss attain maximum
function, independence and quality of life.
*Refer to AOA Clinical Practice Guideline on Care
of the Patient with Visual Impairment
ACTION: Individuals who experience vision loss
from diabetes should be provided, or referred
for, a comprehensive examination of their
visual impairment by a practitioner trained or
experienced in vision rehabilitation.

Central or para-central scotoma from diabetic

maculopathy
Loss of peripheral and mid-central visual field,
secondary to retinal ischemia or panretinal laser
photocoagulation
Reduced dark adaptation and increased lag
times in seeing in dim light
Difficulty with glare
Vision loss resulting from vitreous hemorrhage
or preretinal hemorrhage, or traction retinal
detachment

Visual impairment also has physical, psychological,

behavioral and social consequences that affect
patients, their family, friends and caregivers. Health
care providers and stakeholders may be unaware of
the overall impact of vision loss on the health and
well-being of the patient.
ACTION: Persons with diabetes who experience
visual difficulties should be counseled on the
availability and scope of vision rehabilitation care
and encouraged to utilize these services.

Decreased contrast sensitivity

In addition, important functional sequelae of diabetesrelated vision loss can include:
Inability to self-manage diabetes care, including
monitoring of blood glucose
Difficulty addressing dietary, medical, and other
health-related issues
Difficulty with other health care tasks (such as
checking feet and trimming nails)
Loss of, or restriction in, drivers license
and subsequent limitations on independent
transportation
Inability to maintain wellness and comply with
preventive health measures

The Veterans Affairs model for treatment of vision

impairment has demonstrated effectiveness in
patients with vision impairment resulting from macular
diseases. The Veteran Affairs model involves at least
10 hours of low-vision therapy, including a home visit
and assigned homework to encourage practice, for
patients with moderate and severe vision loss from
230
macular diseases. (B/B)
Vision-related quality of life is influenced strongly by
nonvisual factors, particularly physical and mental
231
health. (C/B) The fear of vision loss associated
with diabetic retinopathy can result in a high level
of anxiety for any individual with diabetes, and for
their family members, regardless of the level of visual
232,233
impairment.
Even those without retinopathy
or other ocular complications may have personal
concerns about diabetes (e.g. problems accepting

51

the disease, adapting to it and adjusting to emotional

and social changes). An early counseling visit may be
beneficial for a family with a child who has diabetes.
ACTION: Referral for counseling is indicated
for any individual experiencing difficulty dealing
with vision and/or health issues associated with
diabetes or diabetic retinopathy. Educational
literature and a list of support agencies and other
resources should be made available to these
individuals.

D. SUMMARY
The Institute of Medicines report Living Well with
Chronic Illness highlights various chronic illnesses,
including diabetes and vision loss. Chronic illnesses
have diverse outcomes, including emotional distress,
physical impairments and age-related degenerative
problems that detract from the quality of life.
While preventive care is best, until therapies are
available to prevent or cure diabetic retinopathy and
other complications of diabetes, emphasis must be
placed on proper diagnosis, careful follow-up, timely
treatment and vision rehabilitation for individuals with
diabetic eye disease.
These individuals should be encouraged to see their
diabetes care providers to work toward achieving
good diabetes control. Proper care will result in
reduction of personal suffering and a substantial cost
savings for the involved individuals, their families and
the country as a whole.
All persons with diabetes should be informed of the
possibility of developing retinopathy or other nonretinopathy ocular complications, with or without
symptoms, and of the associated threat of vision
loss. The natural course and treatment of diabetic
retinopathy should be discussed with the person and
the importance of lifelong eye examinations should
be stressed.
In addition, they should be advised of the availability
of vision rehabilitation to address functional issues
related to vision loss, and provided with referral or
treatment for diabetes-related vision loss.

52

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Washington (D.C.): Department of Veterans Affairs, Department of Defense; 2006.
223. Ford ES. Trends in the risk of coronary heart disease among adults with diagnosed diabetes in the U.S.: findings from the National
Health and Nutrition Examination Survey, 1999-2008. Diabetes Care 2011; 34:1337-43.
224. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific
statement from the American Heart Association and the American Diabetes Association. Diabetes Care 2007; 30:162-72.
225. American Diabetes Association. Physical activity/exercise and diabetes mellitus. Diabetes Care 2003; 26 (suppl 1) s73-75.
226. Johnson WD, Brashear MM, Gupta AK, et.al. Incremental weight loss improves cardiometabolic risk in extremely obese adults.
The American J of Medicine 2011; 124:931-38.
227. American Diabetes Association. Nutritional principles and recommendations in diabetes. Diabetes Care 2004; 27 (suppl 1):s36-39.
228. Joslin Diabetes Center. Oral diabetes medications summary chart. https://joslin.org/info/oral_diabetes_medications_summary_chart.
html. Accessed January 27, 2013.
229. Yeh HC, Brown TT, Maruthur N, et al. Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring
for diabetes mellitus: a systematic review and meta-analysis. Ann Intern Med 2012; 157:336-47.
230. Stelmack JA, Tang XC, Reda DJ, et al. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT).
Arch Ophthalmol 2008; 126:608-17.
231. Trillo AH, Dickinson CM. The impact of visual and non-visual factors on quality of life and adaptation in adults with visual
impairment. Invest Ophthalmol Vis Sci 2012; 53:4234-41.
232. Shindell S. Psychological sequelae to diabetic retinopathy. J Am Optom Assoc 1988; 59:870-4.
233. Wulsin LR, Jacobson AM, Rand LI. Psychosocial aspects of diabetic retinopathy. Diabetes Care 1987; 10:367-73.

66

Appendix Figure 1

Figure 1

Optometric ManagementOptometric
of the Patient
With Undiagnosed
Diabetes Mellitus: A Flowchart
Management
of the Patient

With Undiagnosed Diabetes Mellitus: A Flowchart

Patient
assessment

Suspect undiagnosed diabetes

No ocular
manifestations

Ocular
manifestations

Request A1C /fasting blood glucose

or refer for testing

A1C < 5.7%

or
fasting blood
glucose
<110 mg/dL

A1C
5.7 to 6.4%
or
fasting blood
glucose
110 -125mg/dL

A1C 6.5%
or
fasting blood
glucose
126 mg/dL

Non-retinal
abnormality

Non-proliferative
retinopathy

Manage or
refer per Guideline
Schedule
follow-up eye
examination

Re-test A1C or
fasting blood
glucose

Refer for
evaluation

Schedule
follow-up eye
examination

67

Proliferative
retinopathy

Diabetic
macular
edema

Refer for
treatment of diabetes

Appendix Figure 2
Optometric Management of the Patient With Diagnosed Diabetes Mellitus: A Flowchart

Patient
assessment

Individual known to have:

No retinal
manifestations

Non-proliferative
retinopathy

No ocular
manifestations

Schedule follow-up
eye examination

Proliferative
retinopathy

Manage or refer
per Guideline

Communicate with
physician treating persons
diabetes

Counsel patient
regarding risk for ocular
manifestations

Communicate
with physician treating
patients diabetes

68

Diabetic
macular edema

Appendix Figure 3
Early Treatment of Diabetic Retinopathy Study Standard Photographs

Moderate nonproliferative diabetic retinopathy

Macular edema

IRMAs (standard photograph 8A)

Venous beading (standard photograph 6B)

NVE (standard photograph 7)

NVD (standard photograph 10A)

(standard photograph 2A)

Photo references use the Airlie House classification system.

69

Appendix Table 1
Comparison of ETDRS and International Clinical Diabetic Retinopathy
and Macular Edema Severity Scale
Diabetic Retinopathy

ETDRS

International Scale

No apparent DR

No abnormalities

Mild NPDR

At least one Ma

Ma only

Moderate NPDR

H/Ma > standard photo 2A or soft

exudates, VB and IRMA present

More than just Ma, but less than

severe NPDR

Severe NPDR

One of the following:

No signs of PDR, with any of the

following:

H/Ma standard photo 2A in

all 4 quadrants
VB present in at least 2
quadrants
RMA standard photo 8A in
at least 1 quadrant
PDR

One or both of the following:

Neovascularization, Vitreous/
preretinal hemorrhage

Mild PDR

One or more of the following:

NVE, FPD or FPE present, NVD
and NVE present

Moderate PDR

One or more of the following:

High-risk PDR

>20 intraretinal hemorrhages in

each of 4 quadrants
Definite VB in 2 quadrants
Prominent IRMA in 1
quadrant

NVE elevated
NVD < standard photo 10A
VH/PRH and NVE < DA
NVD absent

One or more of the following:

NVD to 1/3 DA
(standard photo 10A)
NVD and VH/PHR
NVE DA and VH/PRH

70

Appendix Table 1 (continued)

Diabetic Macular Edema

ETDRS

International Scale

DME apparently absent

No apparent retinal thickening or

HE in posterior pole

DME apparently present

Some apparent retinal thickening

or HE in posterior pole

Mild DME

Retinal thickening within 2 DD of

center of the macula

Some retinal thickening or HE in

posterior pole, but distant from
center of the macula

Moderate DME

Retinal thickening or HE
approaching, but not involving, the
center of the macula

Severe DME

Retinal thickening or HE involving

the center of the macula

CSME

One or more of the

following:
Thickening of the retina
500 microns from the center
of the macula
HE 500 microns from the
center of the macula with
thickening of the adjacent
retina
A zone or zones of retinal
thickening 1 DA in size,
any portion of which is 1
DD from the center of the
macula

Sources: Early Treatment Diabetic Retinopathy Study Research Group. Grading diabetic retinopathy from
stereoscopic color fundus photographs: an extension of the modified Airlie House classification. ETDRS
Report No. 10. Ophthalmology 1991; 98:786-806.
Wilkinson CP, Ferris FL, Klein RE, et al. Proposed international clinical diabetic retinopathy and diabetic
macular edema disease severity scales. Ophthalmology 2003;110:1677-82
DR Diabetic retinopathy
NPDR Non-proliferative diabetic retinopathy
PDR Proliferative diabetic retinopathy
DME Diabetic macular edema
CSME Clinically significant macular edema
See Abbreviations of Commonly Used Terms on page 74

71

Appendix Table 2
Effects of Systemic Medications on the Onset and Progression of Diabetic Retinopathy

REVIEWS
Table 1 | Effects of currently available systemic medications on diabetic retinopathy
Systemic agents

Prototypical
drugs

Systemic effects

Specific ocular
mechanism

References
(Author or study)

Implications for diabetes eye-care

Agents for glycemic control

Insulin

Insulin lispro
Insulin
glargine
Isophane
insulin

Regulates
carbohydrate,
lipid and protein
metabolism

Increased VEGF gene

expression36
Alterations in retinal
blood flow with improved
glycemic control19

UKPDS27,34
DCCT32
EDIC30

Glycemic control with HbA1c target of <7%

significantly reduces the risk of developing or
worsening of DR27,30,32,34
Risk of early worsening following initiation of
intensive control and large reduction in HbA1c levels
in patients with poorly controlled long-standing DM
with moderate NPDR or worse39
Potentially angiogenic at very high non-physiologic
doses46,47

Thiazolidinediones

Rosiglitazone
Pioglitazone

Improves insulin
sensitivity

PPAR agonist activity50

Decreased VEGF
production52

Shen etal.51
Fong etal.57

Delays the onset of PDR51

May cause DME56,57

Biguanides

Metformin

Improves glycemic
control
Cardioprotective
effects

Decreased
concentrations of PAI-162
Inhibition of NFB
and TSP-164

UKPDS60

First line oral hypoglycemic agent particularly

beneficial in T2DM patients with overweight or
obesity and cardiovascular risk factors59
Clinical implications independent of glycemic
control have yet to be fully determined

Agents for lipid control

Fibrates

Fenofibrate
Clofibrate
Etofibrate

Improves lipid
parameters
(increases HDL
cholesterol levels,
reduces levels of
total and LDL
cholesterol and
triglycerides)

PPAR agonist activity70

FIELD25
ACCORD Eye82

Reduces the need for laser treatment by 31%25

May reduce the rate of progression in patients
with DR25,76,77
Control of lipid parameters in patients with DME
may result in improved visual outcomes66
Intensive treatment using a combination of
fibrates and statins for lipid control may reduce
the risk of DR progression by 40%82

Statins

Atorvastatin
Simvastatin

Improves lipid
parameters
(reduces total and
LDL cholesterol
levels)

Potential antiinflammatory effects

through NFB inhibition153
Decreased TNF-induced
ICAM1 expression153

Steno-279
CARDS80

Evidence still insufficient to support primary use

to prevent DR progression78
Control of lipid parameters in patients with DME
may result in improved visual outcomes66

Agents blood pressure control

ACE inhibitors

Captopril
Enalapril
Lisinopril

Blocks the
conversion of
angiotensin-1 to
angiotensin-2

Renin-angiotensin system
blockade83
Vitreous activity of ACE
is correlated with VEGF
levels85

UKPDS88
EUCLID89
RASS91

Tight blood pressure control reduces the risk for

two-step DR progression by 34% and three-line
visual loss by 47%88
Treatment with enalapril in normotensive patients
with T1DM reduces the risk for two-step or more
progression by 65%91

ARB

Candesartan
Losartan
Telmisartan
Losartan

Blocks the
activation of
angiotensin-2

Renin-angiotensin system
blockade83
PPAR agonist activity52

RASS91
DIRECT
(Prevent1;
Protect 1
and 2)92,93

Treatment with losartan in normotensive T1DM

patients has been shown to reduce the risk for
two-step or more progression by 65%91
Patients with T2DM and DR may benefit from
candesartan treatment as this has been
associated with higher rates of DR regression92

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin-2 receptor blocker; DM, diabetes mellitus; DME, diabetic macula edema; DR, diabetic retinopathy; ICAM-1, intercellular
adhesion molecule 1; NFB, nuclear factor B; NPDR, nonproliferative diabetic nephrophathy; PAI-1, plasminogen activator inhibitor 1; PDR, proliferative diabetic nephrophathy; PPAR,
peroxisome proliferator-activated receptor; T1DM, type1 diabetes mellitus; T2DM, type2 diabetes mellitus; TNF, tumor necrosis factor; TSP-1, thrombospondin-1; VEGF, vascular endothelial
growth factor.

72

Appendix Table 2 (continued)

Effects of Systemic Medications on the Onset and Progression of Diabetic Retinopathy

REVIEWS
Table 2 | Effects of currently available systemic medications on diabetic retinopathy
Systemic agents

Prototypical
drugs

Systemic effects

Specific ocular
mechanism

References
(Author or study)

Implications for diabetes eye-care

Agents for cardiac complications

Antiplatelet agents

Aspirin

Decreased platelet
activation and
aggregation
Decreased
prostaglandin
production

Low doses: inhibition

of COX1and TBXA2
production104
Intermediate to high
doses: inhibition of
COX1, prostaglandin
production and
NFBmediated
pathways102104

ETDRS96
DAMAD98
TIMAD105

Does not worsen DR or predispose to

vitreous hemorrhage96
At intermediate to high doses may
theoretically slow the progression of
early DR103,104

Anticoagulants

Warfarin
Heparin

Inhibits synthesis of
clotting factors

Inhibits synthesis of
clotting factors106

Dayani etal.110,111
Jamula etal.108
Fu etal.109

If maintained at the therapeutic range, it is

not a contraindication to ocular surgery108111
Does not increase the risk for intraocular
hemorrhage106

Cardiac glycosides

Digoxin
Digitoxin

Antiarrhythmic agent;
Inhibits Na+/K+ATPase

Inhibition of KLK
expression118,120
Reduces HIF1
levels116

Prassas etal.118
Phipps etal.120

Can potentially inhibit ocular

neovascularization and retinal vascular
leakage116
Studies are presently being conducted
to determine safety and efficacy

Stimulates increased
red blood cell
production

VEGFindependent
angiogenic factor124

Watanabe etal.124
Tong etal.125

Patients requiring treatment with

erythropoietin should be monitored closely
for the development or worsening of DR
particularly in the setting of chronic renal
disease and anemia125

Agents for the treatment of anemia

Erythropoietin

Erythropoietin

Anti-inflammatory agents
Salicylates and
COX2 inhibitors

Salsalate
Celecoxib

Inhibits prostaglandin
synthesis

Inhibition of COX
and prostaglandin
production103
Suppression of
NFBmediated
pathways128

Fleischman
etal.128
Chew etal.129

Concern on cardiovascular safety with

longterm use and higher doses130
Theoretically may slow the progression of
early DR103,104

Corticosteroids

Prednisone
Triamcinolone

Modulation of
inflammatory
response

Inhibition of
prostaglandin release
Inhibition of VEGF
gene expression154

DRCR.net131,136,137

An independent beneficial effect of systemic

corticosteroids on the development or
progression of DR and/or DME has not been
reported and is likely overshadowed by
adverse effects

Bevacizumab
Ranibizumab

Inhibits tumor growth

and angiogenesis

Inhibition of all VEGF

isoforms155

Moshfeghi etal.149
Avery etal.115
Scott etal.145
Chun etal.143
Arevalo etal.142
DRCR.net146

Systemic delivery limited by adverse effects149

Intravitreal administration has shown benefit
in regression of PDR115 and resolution of
DME142,143,145
Benefit of intravitreal ranibizumab over
laser reported146
Ongoing clinical trials to elucidate
optimal use

Antiangiogenic agents
VEGF inhibitors

Abbreviations: COX, cyclooxygenase (also known as prostaglandin G/H synthase); DME, diabetic macula edema; DR, diabetic retinopathy; HIF1, hypoxiainducible factor 1; KLK, kallikrein;
NFB, nuclear factor B; Na+/K+ATPase, sodium/potassiumtransporting ATPase; PDR, proliferative diabetic nephrophathy; TBXA2, thromboxane A2; VEGF, vascular endothelial growth factor.

Source: Silva PS, Cavallerano JD, Sun JK, et al. Effect of systemic medications on onset and
progression of diabetic retinopathy. Nat Rev Endocrinol 2010;9:494-508

73

Abbreviations of Commonly Used Terms

A1C - Glycosylated hemoglobin
ACE - Angiotensin converting enzyme
ADA - American Diabetes Association
BMI - Body mass index
CSME - Clinically significant macular edema
CVD - Cardiovascular disease
DA/DCCT - Disc area
EDIC - Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and
Complications
DD - Disc diameter
DME - Diabetic macular edema
DR - Diabetic retinopathy
DRCR.net - Diabetic Retinopathy Clinical Research Network
DRVS - Diabetic Retinopathy Vitrectomy Study
DRS - Diabetic Retinopathy Study
EHR - Electronic health record
ETDRS - Early Treatment Diabetic Retinopathy Study
FA - Fluorescein angiography
FAF - Fundus autofluoresence
FDA - Food and Drug Administration
FPD - Fibrous proliferation on or within 1 DD of disc margin
FPE - Fibrous proliferation elsewhere, not FPD
FPG - Fasting plasma glucose
GAD65 - Glutamic acid decarboxylase
GDM - Gestational diabetes mellitus
HDL - High-density lipoprotein(s)
HE - Hard exudates
HLA - Human leukocyte antigen(s)
H/Ma - Hemorrhage(s) and/or microaneurysm(s)
IAAs - Insulin autoantibodies
ICAs - Islet cell antibodies
IFG - Impaired fasting glucose
IGT - Impaired glucose tolerance

74

 IOP - Intraocular pressure

IVTA - Intravitreal triamcinolone acetonide
IRMA - Intraretinal microvascular abnormality
LDL - Low-density lipoproteins
Ma - Microaneurysms
NAION - Non-arteritic anterior ischemic optic neuropathy
NPDR - Non-proliferative diabetic retinopathy
NVD - New vessels on or within 1 DD of disc margin
NVE - New vessels elsewhere in the retina outside of disc and 1 DD from disc margin
NVG - Neovascular glaucoma
NVI - New vessels on the iris; rubeosis iridis
OAG - Open angle glaucoma
OCT - Optical coherence tomography
OGTT - Oral glucose tolerance test
PDR - Proliferative diabetic retinopathy
PRH - Preretinal hemorrhage
PRP - Panretinal photocoagulation
PVD - Posterior vitreous detachment
TRD - Traction retinal detachment
UKPDS - United Kingdom Prospective Diabetes Study
VB - Venous beading
VCAB - Venous caliber abnormalities
VEGF -Vascular endothelial growth factor
VH - Vitreous hemorrhage

75

Glossary

the retina greater than l/2 the size of the disc area.

Clinically significant macular edema (CSME)

Hyperglycemia Presence of high blood glucose

levels.

The case where there is retinal thickening at or

within 500 microns of the center of the macular and/
or hard exudates within 500 microns of the center of
the macula associated with retinal thickening of the
adjacent area of the retina and/or a zone or zones
of retinal thickening 1 disc area in size, any part of
which is within 1 disc diameter of the center of the
macula.
Diabetes mellitus A group of metabolic disorders
characterized by hyperglycemia resulting from defects
in insulin secretion, insulin action, or both.
Type 1 diabetes The result of cell-mediated
autoimmune destruction of the beta-cells of
the pancreas, formerly referred to as insulin
dependent diabetes mellitus (IDDM).
Type 2 diabetes A disease in which individuals
can produce insulin but have cellular resistance
to it, formerly referred to as non-insulin
dependent diabetes mellitus (NIDDM).
Diabetic cataract A rapidly forming, sometimes
reversible, bilateral cataract associated with diabetes
mellitus.
Diabetic papillopathy A non-inflammatory edema
of the optic nerve head associated with diabetes
mellitus.
Diabetic retinopathy A highly specific retinal vascular
complication of diabetes mellitus, which is broadly
classified as non-proliferative diabetic retinopathy
(NPDR) and proliferative diabetic retinopathy (PDR).
High-risk proliferative diabetic retinopathy New
vessels on or within 1 disc diameter of the optic
nerve head greater than approximately l/4 to l/3
of the disc, or new vessels on or within 1 disc
diameter of the optic nerve head less than l/4 to l/3
the disc area when accompanied by vitreous and/or
preretinal hemorrhage, or new vessels elsewhere in

Insulin A hormone that allows glucose to enter cells

and be converted to energy.
Intraretinal hemorrhage A radially striated
hemorrhage in the inner layers of the retina,
especially in the nerve fiber layer (flame-shaped
hemorrhage).
Intraretinal microvascular abnormality (IRMA)
An abnormality that represents either new vessel
growth within the retina or pre-existing vessels with
endothelial cell proliferation.
Ketoacidosis A serious complication of diabetes
that occurs when the body burns fat producing very
high levels of toxic acids, called ketones, in the
bloodstream.
Legal Blindness Remaining vision in the better
eye after best correction of 20/200 or less, or
contraction of the visual fields in the better eye (a) to
10 degrees or less from the point of fixation or (b)
so that the widest diameter subtends an angle no
greater than 20 degrees.
Macular edema (ME) Collection of intraretinal fluid in
the macular portion of the retina, with or without lipid
exudates, and with or without cystoid changes.
Microaneurysm (Ma) As to the eye, a focal retinal
capillary dilation.
Neovascularization Growth of abnormal new blood
vessels.
Papilledema Non-inflammatory edema of the
optic nerve head from various causes, such as
increased intracranial pressure, orbital tumor or blood
dyscrasias.
Postprandial blood glucose Blood glucose
measurement taken 1 to 2 hours after a meal.

76

Proliferative diabetic retinopathy (PDR) A type

of retinopathy associated with diabetes mellitus,
characterized by proliferation of connective tissue and
the formation of new blood vessels in the retina, and
by hemorrhages into the vitreous.

Sources

Retinal hypoxia A deficiency of oxygen supply to

the retinal tissue.

Rhee DJ, Pyfer MF, eds. The Wills eye manual:

office and emergency room diagnosis and treatment
of eye disease, 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2012

Hofstetter HW, Griffin JR, Berman MS, Everson RW.

Dictionary of visual science and related clinical terms,
5th ed. Boston: Butterworth-Heinemann, 2000.

Rubeosis iridis Non-inflammatory neovascularization

of the iris occurring in diabetes mellitus, characterized
by numerous, small intertwining blood vessels which
anastomose near the sphincter region to give the
appearance of a reddish ring near the border of the
pupil. The vessels may extend from the root of the
iris to the filtration angle to cause peripheral vascular
synechiae and secondary glaucoma.

Stedmans medical dictionary, 28th ed. Baltimore:

Williams & Wilkins, 2005
Sanchez CR, Silva PS, Cavallerano JP, et al. Ocular
telemedicine for diabetic retinopathy and the Joslin
Vision Network. Seminars in Ophthal 2010;25:218-24.

Severe Visual Impairment Best-corrected visual

acuity of 5/200 or worse.
Telehealth programs Refers to remote health care
that does not always involve clinical services and
may include videoconferencing, transmission of still
images, remote monitoring of vital signs, continuing
medical education and nursing call centers.
Venous beading (VB) A fragmented appearance of
the bloodstream in the retinal veins subsequent to
retinal artery occlusion.
Vision rehabilitation The process of treatment and
education that helps individuals who are visually
disabled attain maximum function, a sense of wellbeing, a personally satisfying level of independence
and optimum quality of life. Function is maximized
by evaluation, diagnosis and treatment including, but
not limited to, the prescription of optical, non-optical,
electronic and/or other treatments.

77

Summary Listing of Action

Statements
Diagnosis of Ocular Complications of
Diabetes Mellitus
The ocular examination of an individual suspected
of having undiagnosed diabetes should include all
aspects of a comprehensive eye examination with
supplemental testing, as needed.

Persons without a diagnosis of diabetes who present
with signs suggestive of diabetes during the initial
examination should be referred to their primary care
physician for evaluation, or an A1C test or fasting
blood glucose analysis may be ordered.

The ocular examination of a person with diabetes
should include all aspects of a comprehensive
eye examination with supplemental testing, as
indicated, to detect and thoroughly evaluate ocular
complications.

Patients should be questioned about the awareness
of their personal diabetes ABCs (A1C, blood
pressure, cholesterol levels, and their history of
smoking).

The initial ocular examination should include, but is
not limited to, the following evaluations:

Retinal examinations for diabetic retinopathy should

be performed through a dilated pupil.

When vitreous hemorrhage prevents adequate
visualization of the retina, prompt referral to an
ophthalmologist experienced in the management of
diabetic retinal disease should be made for further
evaluation.

The individuals primary care physician should be
informed of eye examination results following each
examination, even when retinopathy is minimal or not
present.

As diabetes may go undiagnosed for many years,
any individual with type 2 diabetes should have a
comprehensive dilated eye examination soon after the
diagnosis of diabetes.

Individuals with diabetes should receive at least
annual dilated eye examinations. More frequent
examination may be needed depending on changes
in vision and the severity and progression of the
diabetic retinopathy.

Women with pre-existing diabetes who are planning
pregnancy or who become pregnant should have a
comprehensive eye examination prior to a planned
pregnancy or during the first trimester, with follow-up
during each trimester of pregnancy.

Best-corrected visual acuity

Pupillary reflexes

Examination of persons with non-retinal ocular

complications of diabetes should be consistent with
current recommendations of care for each condition.

Ocular motility
Refractive status
Confrontation visual field testing or visual
field evaluation
Slit lamp biomicroscopy
Tonometry

Prompt referral to a vitreo-retinal surgeon is indicated
when a vitreous hemorrhage, a retinal detachment, or
other evidence of proliferative diabetic retinopathy is
present.

Dilated retinal examination

78

Treatment and Management

Treatment protocols for persons with non-retinal
ocular and visual complications should follow current
recommendations for care and include education on
the subject and recommendations for follow-up visits.

Diabetic Macular Edema

Following focal photocoagulation for DME, reexamination should be scheduled in 3 to 4 months.

As part of the proper management of diabetes, the
optometrist should make referrals for concurrent care
when indicated.

Patients with center-involved diabetic macular edema

(DME) should be referred to an ophthalmologist
experienced in the management of diabetic retinal
disease for possible treatment.

Non-proliferative Diabetic Retinopathy

Panretinal photocoagulation may be considered in

patients with severe or very severe non-proliferative
diabetic retinopathy (NPDR) or early proliferative
diabetic retinopathy (PDR), with a high risk of
progression (e.g. pregnancy, poor glycemic control,
inability to follow-up, initiation of intensive glycemic
control, impending ocular surgery, renal impairment,
rapid progression of retinopathy).[Evidence Strength:
A, Recommendation: A]

Individuals with diabetic macular edema (DME), but

without clinically significant macular edema (CSME),
should be re-examined at 4- to 6-month intervals.
Once CSME develops, treatment with focal laser
photocoagulation or intravitreal anti-VEGF injection is
indicated. [Evidence Strength: A, Recommendation: A]
Vitrectomy
Eyes with vitreous hemorrhage (VH), traction retinal
detachment (TRD), macular traction or an epiretinal
membrane should be referred to an ophthalmologist
experienced in the management of diabetic retinal
disease for evaluation for possible vitrectomy.

Proliferative Diabetic Retinopathy

Patients with high-risk proliferative diabetic retinopathy
should receive referral to an ophthalmologist
experienced in the management of diabetic
retinal disease for prompt scatter (panretinal)
photocoagulation. [Evidence Strength: A/B,
Recommendation A/B]

Anti-VEGF Agents
The current standard of care for treatment of centerinvolved diabetic macular edema (DME), in persons
with best corrected visual acuity of 20/32 or worse,
is anti-VEGF injections. [Evidence Strength: A,
Recommendation: A]

Eyes in which proliferative diabetic retinopathy has
not advanced to the high-risk stage should also
be referred for consultation with an ophthalmologist
experienced in the management of diabetic retinal
disease. [Evidence Strength: A/B, Recommendation
A/B]

Patient Education

Following successful treatment with panretinal
photocoagulation (PRP), patients should be reexamined every 2 to 4 months. The follow-up interval
may be extended based on disease severity and
stability.

Persons should be educated about the ocular signs

and symptoms of diabetic retinopathy and other nonretinal complications of diabetes, and encouraged
to comply with recommendations for follow-up eye
examinations and care.

Individuals should be advised of the risks of smoking
related to diabetes and encouraged to quit smoking
and/or seek smoking cessation assistance.

79

Individuals should be educated about the long-term

benefits of glucose control in saving sight, based on
their individual medically appropriate A1C target.
Management of Systemic Complications and
Comorbidities of Diabetes Mellitus
The glycemic goal for persons with diabetes should
be individualized, taking into consideration their risk
of hypoglycemia, anticipated life expectancy, duration
of disease and co-morbid conditions.

encouraged to utilize these services.

Referral for counseling is indicated for any individual
experiencing difficulty dealing with vision and/or
health issues associated with diabetes or diabetic
retinopathy. Educational literature and a list of
support agencies and other resources should be
made available to these individuals.

Optometrists should have a rapid-acting carbohydrate
(e.g. glucose gel or tablets, sugar-sweetened
beverage or fruit juice) in their office for use with
diabetes patients who experience acute hypoglycemia
during an eye examination.

The majority of persons with diabetes are at risk of
coronary heart disease and can benefit from reducing
low-density lipoprotein (LDL) cholesterol levels to the
currently recommended targets. [Evidence Strength: B,
Recommendation: B]

When indicated, overweight individuals should be
referred to a qualified health care provider for
assistance with weight loss.

Individuals with diabetes should receive nutrition
and dietary recommendations preferably provided by
a registered dietician who is knowledgeable about
diabetes management.
Management of Persons with Vision Loss/Visual
Impairment
Individuals who experience vision loss from
diabetes should be provided, or referred for, a
comprehensive examination of their visual impairment
by a practitioner trained or experienced in vision
rehabilitation.

Persons with diabetes, who experience visual
difficulties, should be counseled on the availability
and scope of vision rehabilitation care and

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VIII. Methodology for Guideline

Development

Mayo Clinic

his Guideline was developed by the AOA

Evidence-Based Optometry Guideline
Development Group (GDG). Clinical questions
to be addressed in the Guideline were identified and
refined during an initial meeting of the GDG and
served as the basis for a search of the clinical and
research literature.

National Guideline Clearinghouse of the Agency

for Healthcare Research and Quality (AHRQ)

An English-language literature search for the

years 2009-2012 was conducted by two trained
researchers. If the search did not produce results,
the search parameters were extended to 5 years
earlier and subsequently, 10 years earlier. In addition,
a review of selected earlier research publications
was conducted based on previous versions of this
Guideline. The literature search was conducted using
the following electronic databases:

National Library of Medicine Loansome Doc

Agency for Healthcare Research and Quality

(AHRQ)
American Academy of Ophthalmology
American Diabetes Association professional for
the site Diabetes Pro Standards of Medical
Care in Diabetes 2011
American Optometric Association
Cochrane Collection
Diabetes Prevention Program
Diabetic Retinopathy Clinical Research Network
Diabetologia (International)
Elsevier
European Association for the Study of Diabetes
(EASD) Eye Complications Study Group
European Association for the Study of Diabetes
(EASD, Europes ADA)
Eye (Journal)
Guidelines International Network
Institute of Medicine Clinical Guideline Welcome
Trust

Medical Expenditure Panel Survey (MEPS)

National Institute for Clinical Effectiveness

(British)
National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK) National Diabetes
Information Clearinghouse
NEI National Eye Institute
Ophthalmologica (International Journal of
Ophthalmology)
PubMed
World Health Organization
All references meeting the criteria were reviewed to
determine their relevance to the clinical questions
addressed in the Guideline. They were distributed
to two readers who independently reviewed and
graded the quality of evidence and the clinical
recommendations for each article, based on a
previously defined system for grading quality.
A total of 576 papers were identified and filtered for
relevance as meeting the key question parameters.
Of this number, 298 were categorized as background
information and provided to the medical writer. A
total of 278 articles were reviewed independently by
the two readers and graded on strength of evidence
and clinical recommendations. Any gaps in evidence
were also noted at this time for future review of this
Guideline.
Of the 278 papers read and graded by the GDG,
94 were found to have high-quality of evidence value
and/or high grading for clinical recommendations
and were included in the Guideline references. One
hundred and twenty articles were discarded because
they failed to meet the criteria for strength of
evidence and/or clinical recommendation for inclusion
in the Guideline. The remaining 64 articles were
discarded because they did not appropriately address
the Guideline questions.

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During two articulation meetings of the Evidence-Based Optometry GDG, all evidence was reviewed and
clinical recommendations were developed. Grading for the recommendations were based on the quality of
the research and the benefits and risks of the procedure or therapy recommended. Where direct scientific
evidence to support a recommendation was weak or lacking, a consensus of the Evidence-Based Optometry
Subcommittee members was required to approve a recommendation.
At the Draft Reading Meeting of the Evidence-Based Optometry GDG, the Guideline document was reviewed
and edited and the final draft was approved by the GDG via conference call. The final draft of the Guideline
was then made available for peer and public review for 30 days in order for numerous stakeholders
(individuals and organizations) to make comments. All suggested revisions were reviewed and, if accepted by
the GDG, incorporated into the Guideline.
Clinical recommendations in this Guideline are evidence-based statements regarding patient care that are
supported by the scientific literature or consensus professional opinion when no quality evidence was
discovered. The Guideline will be periodically reviewed and updated as new scientific and clinical evidence
becomes available.

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X. Evidence-based Optometry Guideline Development Group

This Guideline was authored by the following individuals:
AOA Evidence-Based Optometry Committee

Non-Voting Members
Stephen C. Miller, O.D. Chief Editor12

Diane T. Adamczyk, O.D., Chair1

Beth A. Kneib, O.D. AOA Director of Clinical

Resources13

John F. Amos, O.D., M.S.2

Felix M. Barker, II, O.D., M.S.3

Danette Miller AOA Manager of Quality

Improvement14

A. Paul Chous, M.A., O.D.4

Linda M. Chous, O.D.5

Alisa G. Krewet AOA Quality Improvement

Coordinator15

Lynn D. Greenspan, O.D.

Lori L. Grover, O.D., Ph.D.7

Multidisciplinary and Patient Stakeholders

Tina R. MacDonald, O.D., CDE*8

Jerry Cavallerano, O.D., Ph.D.16

David K. Masihdas, O.D.9

William Hsu, M.D.17

Bennett McAllister, O.D.10

Katherine K. Killilea, M.Ed.18

Carl J. Urbanski, O.D.11

Paolo Antonio S. Silva, M.D.19

Evelyn Smith DeMille, M.S., M.P.H.20
Medical Editor
Evra Taylor21

1. State University of New York, College of Optometry, New York, New York
2. University of Alabama at Birmingham School of Optometry, Birmingham, Alabama, Retired Dean
3. W. G. (Bill) Hefner VAMC, Salisbury, North Carolina
4. Chous Eyecare Associates, Tacoma, Washington
5. United HealthCare Services, Inc., Minneapolis, Minnesota
6. Salus University, Pennsylvania College of Optometry, Elkins Park, Pennsylvania
7. Center for Translational Health Science, Arizona State University, Phoenix, Arizona
8. Certified Diabetes Educator, The Center for the Partially Sighted, Culver City, California
9. Utah Eye Associates - The Diabetic Eye Center, Salt Lake City, Utah
10. Western University of Health Sciences, College of Optometry, Pomona, California
11. Family Vision Care of Kingston, Kingston, Pennsylvania
12. Innovative Writing Works, St. Louis, Missouri
13. American Optometric Association, St. Louis, Missouri
14. American Optometric Association, St. Louis, Missouri
15. American Optometric Association, St. Louis, Missouri
16. Beetham Eye Institute, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
17. Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
18. Patient Advocate, Wilmington, Massachusetts
19. Beetham Eye Institute, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
20. Patient, Arlington, Massachusetts
21. Medical Editor, Journalist, Copywriter

83