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DIABETES INFO SERIES I
MOH/K/EPI/05.97 (GU)
Edaran Umum
ISBN : 983-9417-07-X
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Copyright  Ministry of Health Malaysia
 Academy of Medicine
Published by
• Ministry of Health Malaysia
• Academy of Medicine
Distributed by
Diabetes and Blindness Unit
Disease Control Division
Ministry of Health Malaysia
Block E, Jalan Dungun, Bukit Damansara
50490 KUALA LUMPUR
Printed by
AG GRAFIK SDN.BHD
October 1997
FOREWORD
Diabetes is one of the most prevalent chronic conditions among Malaysians.
Complications of diabetes including diabetic retinopathy need close attention. Diabetic
retinopathy is now the leading cause of blindness amongst Malaysian adults. More than
half of diabetic cases will eventually develop pathological changes in both eyes in a
matter of years which will then lead to blindness.
Careful control of diabetes is critical to prevent its complications. Likewise
appropriate skill in detecting complications such as diabetic retinopathy and an up to date
knowledge in the management of diabetic complications is absolutely essential.
The Ministry of Health has taken the initiative to produce this guideline to assist
doctors as well as paramedics to provide proper management of diabetic cases. It is
hoped that this guideline will be of great help to those who are directly involved in the
management of diabetic retinopathy patients.
TAN SRI DATO’ (DR.) ABU BAKAR SULEIMAN
DIRECTOR GENERAL OF HEALTH MALAYSIA
MEMBERS OF THE COMMITTEE FOR DIABETIC RETINOPATHY
NAMES
Dr. (Mrs.) G. Arumugam
Consultant Ophthalmologist,
Head of Department
Hospital Kuala Lumpur
Dr. Mariam Mohd. Ismail
Consultant Ophthalmologist
Hospital Kuala Lumpur
Dr. Anusiah Selvathurai
Consultant Ophthalmologist
Hospital Kuala Lumpur
Assoc. Prof. Dr. Alias Dahlan
Consultant Ophthalmologist
Department of Ophthalmology
Universiti Kebangsaan Malaysia
Dr. Zainal Mohamad
Consultant Ophthalmologist
Department of Ophthalmology
Universiti Kebangsaan Malaysia
Dr. Rokiah pendek
Endocrinologist
Department of Medicine
Hospital University
Kuala Lumpur
Dr. Hj. Ismail Samad
Assistant Director (Blindness)
Disease Control Division
Ministry of Health Malaysia
Dr. Pall Singh
Consultant Ophthalmologist
Tun Hussein Onn National
Eye Hospital
Chairman Ophthalmological
Society, MMA
S/N Minah Ibrahim
Department of Ophthalmology
Hospital Kuala Lumpur
MEMBERS OF THE WORKSHOP ON CLINICAL PRACTICE GUIDELINES
FOR DIABETIC RETINOPATHY HELD ON 30-31 OCTOBER 1996 AT HILTON
HOTEL, KUALA LUMPUR, DURING THE FIRST MOH AMM SCIENTIFIC
MEETING
Dr. Ahmad Mat Saad
Dr. Mohd Musadiq
Dr. Aishah Abu Baker
S/N Minah Ibrahim
Dr. Amiruddin Hisan
Dr. Ong Chee Leng
Asso. Prof. Dr. Alias Dahlan
Dr. M. Sharif Fahruddin
Dr. S. Anusiah
Dr. Sanjay Dhir
Dr. Chin Pik Kee
Datin Dr. Selvanayagi
Dr. P. Devarani
Dr. Sharifah Fauziah Syed Alhabsi
Dr. Fadhullah Suhaimi
Dr. Yap Piang Kian
Dato’ Dr. Gurdeep Singh
Dr. Zainal Mohamad
Dr. M. Kauthaman
Dr. Zulkefli Ghani
Dr. Leong Kwok Chi
Dr. Mohd Nasir Kadir
ACKNOWLEDGEMENTS
The members of this committee would like to express our heartfelt appreciation to the
following associations, whose guideline contributed to the preparation of this clinical
practice guidelines.
1.
Scottish Intercollegiate Guideline Network
2.
American Academy of Ophthalmology
CONTENTS
PAGE
Summary
5
Introduction
7
Background
8
Natural History of Diabetic Eye Disease
10-11
Detection of Diabetic Retinopathy
12-13
Prevention and Ocular management of
Diabetic Retinopathy
14-15
Medical Management of Diabetic Retinopathy
16-21
Recommendations for Screening of
Diabetic Retinopathy
22
Conclusions
23
References
24-25
A Quick Reference Guide
26
Appendix I
27
Appendix II
28
Appendix III
29
Eye Care Card (Sample)
30
SUMMARY

Diabetic eye disease is one of the commonest causes of visual loss in adults of
working age in Malaysia.

Sight-threatening diabetic retinopathy causes no symptoms in its early stages, when it
is most amenable to treatment.

About 30% of the diagnosed diabetic population has retinopathy and each year 1%
develop sight-threatening retinopathy.

The incidence of blindness (visual acuity < 3/60 in the better eye) or severe visual
impairment in diabetic patients is currently unknown in Malaysia.

The health authority in Malaysia does not maintain a comprehensive central register
of all diabetic patients.

Duration of diabetes is the most important factor determing the prevalence and
severity of retinopathy

Screening of diabetic eye disease has been proven to prevent loss of sight.
Screening may be undertaken by personnel, using proven techniques.

Good control of diabetes will prevent or retard progression of retinopathy in young
patients with insulin dependant diabetes. Uncontrolled hypertension and smoking are
risk factors for retinopathy.

In 80% of patients with proliferative retinopathy, new vessels will be abolished by
laser treatment.
effectively cured.
Prolonged follow-up indicates that the disease is stabilised or

Vision in 50-60% of patients, with maculopathy, will improve by laser therapy.

Patients and health care providers are frequently unaware of existing provision for
support of visually handicapped diabetic patients.
1.
INTRODUCTION
1.1
This guideline describes the recommendations for reduction of diabetes related
blindness in Malaysia. Blindness is defined as visual acuity (VA) <3/60 in the
better eye and low vision as VA between 6/18 and 6/60 in the better eye, as
recommended by World Health Organisation.
1.2
This guideline was prepared by the working committee established in August
1996, for the committee on Practice Guidelines And Consensus Statements’ of the
Ministry of Health.
1.3
It is hoped that this national guideline will be adopted by all health
care
providers.
1.4
2.0
This guideline will be updated at regular intervals, as the need arises
BACKGROUND
Diabetic retinopathy is an important Public Health problem. It is a highly specific
vascular complication of both type 1 (insulin dependent) and type 2 (non insulin
dependent) diabetes mellitus.
The prevalence of diabetic retinopathy has been measured in several population
based studies. The findings suggest that the prevalence of the more severe grades ranges
from 3 to 6 % of diabetics. In the Winconsin Epidemiologic Study of Diabetic
Retinopathy (WESDR), 3.6% of younger onset patients and 1.6% of older onset patients
were legally blind. In the younger onset group, 86% of blindness was attributable to
diabetic retinopathy. In the older onset group, one third of the cases of legal blindness
were due to diabetic retinopathy. Overall, diabetic retinopathy is estimated to be the most
frequent cause of new blindness among adults, aged 20-70 years.
The National Eye Survey 1996 results show that the prevalence of diabetic
retinopathy among NIDDM aged 40 years and above with duration of more than 5 years
is 14.6%. As the duration increased the prevalence of diabetic retinopathy will become
double. The prevalence of known diabetes in Malaysia among aged 40 years and above
for 1996 is estimated to be 6.6% or about 300,000 people and 30% of these are suffering
from diabetes for more than 5 years. Hence about 13,000 people are estimated to have
diabetic retinopathy.
Although the statistics on blindness due to diabetic retinopathy is lacking, the
existing hospital based data has shown that it is becoming an increasingly important cause
of blindness. This is as a consequence of the rising prevalence of diabetes due to the
change in lifestyles, improved medical care and the aging population.
Apart from these, several problems exist in the early detection and treatment
of diabetic retinopathy. Firstly, many diabetics are not aware that diabetes can
cause blindness. The implication is that unless they are referred for screening they
will not do so their own.
Secondly, the majority of the diabetics are being treated at the primary health care
level (General Practitioners Clinics, Out Patient Department, Health Centers). The sheer
number of patients and the lack of skill in detecting diabetic retinopathy by direct
ophthalmoscopy hampers effective screening.
The present system, in most hospitals, where diabetic fundi are screened only by
the ophthalmologists and the physicians, in the setting of a busy clinic practice, is again
unsatisfactory and will only reach a small percentage of diabetics. This is compounded by
the lack of uniformity in their management.
A well recognized and coordinated nationwide diabetic screening and treatment
programme will therefore do much to reduce the incidence of diabetic related blindness.
3.0
NATURAL HISTORY OF DIABETIC EYE DISEASE
Diabetic retinopathy is a manifestation of diabetic micro-angiopathy and it is thought to
evolve through several stages. In general, progression of retinopathy advances from
background abnormalities to pre-proliferative retinopathy and proliferavtive retinopathy.
It is believed that these complications are direct consequences of long term
hyperglycaemia. Several large studies have confirmed the observation that the duration of
diabetes is the most important correlate of prevalence and severity of diabetic retinopathy.
Diabetic retinopathy in young people with Type 1 diabetes do not occur for at
least 3-5 years, after the onset of the systemic disease. Similar results have been obtained
for persons with Type 2 but in this cases, the time of onset and therefore the duration are
more difficult to determine precisely.
Visual loss results from either macula edema and capillary non perfusion or from
proliferative disease, where contraction of the new blood vessels and their accompanying
fibrous tissue leads to tractional retinal detachment and recurrent vitreous haemorrhage.
These sight threatening retinopathies however cause no symptoms in the early stages
when it is most amenable to treatment.
Studies, on the time course development of certain lesions of diabetic retinopathy,
have shown that proliferative diabetic retinopathy is more prevalent in Type 1 diabetes,
that is 50% after 15 years. Prevalence of proliferative disease is much less in persons with
Type 2 diabetes of similar duration.
It has been generally assumed that macula edema is much more common in Type
2, but Klein et al found that the prevalence of macula edema as a function of duration is
identical in persons with Type 1 and Type 2 diabetes.
Apart from the duration and type of diabetes, other factors have been described as
having effects in the development and progression of diabetic retinopathy.
Of the risk factors which can be modified, the most important is the control of
diabetes. The WESDR has clearly demonstrated that good diabetic control will prevent
onset and retard progression of retinopathy. Data relating to the relationship between
hypertension or cigarette smoking are inconsistent but both factors seem to accelerate the
disease process.
The effects of pregnancy on diabetic retinopathy have been studied and recently,
Klein et al provided the best evidence that pregnancy promote the progression of diabetic
retinopathy. The mechanism by which puberty might exert its effect on the development
of early retinopathy is unknown, but studies have suggested that hormonal factors may
play a role.
4.0
4.1
DETECTION OF DIABETIC RETINOPATHY
Since diabetic retinopathy is asymptomatic in its early and most easily treatable
stages, the disease can only be detected by clinical examination of the patient’s eyes.
4.2
A screening programme must be comprehensive, that is, covering all persons with
diabetes in a defined geographic area. At present, the Malaysian health authority
does not have a comprehensive register of all diabetic patients.
4.3
The screening examination must include :
1)
measurement of visual acuity
: near and distant vision with
pinhole
with glasses when applicable
2)
fundoscopy performed by
a)
direct ophthalmoscopy
b)
combination of direct ophthalmoscopy with set-lamp
biomicroscopy
c)
retinal photography
d)
indirect ophthalmoscopy
One or more of these methods may performed by general practitioners,
clinicians in a hospitals based diabetes centre, ophthalmologists, or (in the case of
photography) a technician and a medically trained photographic interpreter.
4.4
Primary care physicians provide sole diabetes care for a large proportion of
the diabetic population. Their sole screening method is direct
ophthalmoscopy. Without special training, their accuracy as screeners is
unsatisfactory but is has been established that after a short course of
training, their screening performance reaches a satisfactory level. Whether
or not they perform the screening process personally, they have a key
responsibility for ensuring that all diabetic patients on their practice list are
adequately screened.
4.5
Physicians in hospitals manage about half of all diabetic patients and a much
larger proportion of insulin treated patients. Their knowledge in clinical
diabetes emphasises the importance of retinal screening and with
appropriate training, physicians can be depended on for detection and
interpretation of diabetic retinopathy.
4.6
A proportion of diabetic patients with poor vision visit the optometrists
directly for visual problems, and some of these maybe due to diabetic
retinopathy. Therefore, the optometrists may have a role in the screening
programme, provided they receive training.
4.7
Screening by retinal photography of diabetic eyes through a non-mydriatic
pupil camera is a workable option.
4.8
Ophthalmologists are the clinical ‘gold standard’ as screeners for diabetic
retinopathy as they will detect and classify diabetic retinopathy with very
high sensitivity and specificity. However, the role of the ophthalmologists in a
screening programme is limited by the lack of numbers.
5.0
PREVENTION AND OCULAR MANAGEMENT OF
DIABETIC RETINOPATHY
There are good evidence that the treatment of diabetic retinopathy by laser
photocoagulation of retinal tissue is effective. Two large trials, the Diabetic Retinopathy
Study (DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS) provide the
strongest support for the therapeutic benefit of photocoagulation.
The DRS found that laser treatment will abolish new vessels in about 80% of
patients with proliferative retinopathy.
Prolonged follow-up, for more than 10 years, indicates that the disease is
stabilised or effectively cured in such patients.
The ETDRS established the benefit of laser photocoagulation in eyes with macula
edema. Though laser therapy is less effective for maculopathy, it still induces visual
improvement in about 50%-60% of cases.
Laser photocoagulation, in both the DRS and ETDRS, was beneficial in
preventing further visual loss, but generally not beneficial in reversing already diminished
acuity.
This preventive effect, coupled with the fact that patients with proliferative
retinopathy and macula edema may be asymptomatic, provide strong support for a
screening program to detect diabetic retinopathy.
Measures to significantly reduce the incidence of blindness from diabetes should
include :

Establishing a nationwide diabetic screening programme.

Education and training of medical staff and patients.

Providing adequate treatment and follow up facilities.
6.0
MEDICAL MANAGEMENT OF DIABETEC RETINOPATHY
The DCCT Trial (1993) confirmed that intensive blood glucose control in insulin
dependent diabetes mellitus (IDDM) patients can reduce the risk of retinopathy by 76% in
the primary-prevention cohort and by 54% in the secondary-prevention cohort.
A similar study in type 2 diabetes (NIDDM) patients (UKPDS Study) is still on
going but should probably support the fact that intensive blood glucose control in type 2
diabetes (NIDDM) patients should also be able to decrease the risk of diabetic
retinopathy.
6.1
BLOOD GLUCOSE CONTROL
6.1.1 Type 2 Diabetes (NIDDM)
6.1.1 a. Type 2 diabetes (NIDDM) with background retinopathy
All patients with background retinopathy (BDR) must be encouraged to tighten
blood glucose control to normoglycemia to prevent or delay progression to
preproliferative (PPDR) or proliferative retinopathy (PDR).
Blood glucose control can be achieved acutely or over a period of time by
optimizing diet therapy and oral hypoglycemic agents (OHA). If OHA dose is
already maximal, combination therapy with insulin, bed time insulin daytime
sulphonylurea (BIDS regimen) may help to achieve blood glucose control.
Otherwise, the patient should go on full time insulin therapy. Diabetologist or
endocrinologist should be consulted with regards to insulin therapy.
6.1.1 b. Type 2 diabetes (NIDDM) with severe nPDR/PDR
This group of patients should also be encouraged to tighten their blood glucose
control as in 6.1.1a. However, even though, there is no direct evidence yet linking
deterioration/amelioration of PPDR/PDR in NIDDM patients the rapid
achievement of normoglycemia, precaution should be taken to control blood
glucose over 6 – 9 months instead of acutely over a few weeks (except in
pregnancy – see section 6.1.3)
If using OHA, shorter-acting second-generation sulphonylureas like gliclazide or
glipizide can reduce the risk of hypoglycemia. These agents also claim to offer
some anti-platelet activity but evidence is not unanimous.
There should be close liaison with the ophthalmologist while optimizing blood
glucose control.
6.1.2 Type 1 diabetes (IDDM)
6.1.2 a. Type 1 diabetes (IDDM) with nPDR
All patients should be encouraged to achieve good blood glucose control to near
normoglycemia because of the benefit shown by the DCCT trial.
This can be done by optimizing diet with intensive insulin therapy using the
Basal-bolus regimen.
There is evidence which showns amelioration of retinopathy with acute blood
glucose control over 2 – 3 weeks.
However, there is also plenty of evidence which shows deterioration of
retinopathy when blood glucose is brought down too quickly. Control of blood
glucose should, therefore, be done gradually over 39 months period to prevent
progression of retinopathy associated with acute control of blood glucose (except
in pregnancy – see section 6.1.3).
During optimisation of blood glucose control, there should be frequent ocular
examination (every 2 – 3 months).
6.1.2 b. Type 1 diabetes (IDDM) with severe nPDR/PDR
This group of patients should also be encouraged to tighten the blood glucose
control gradually over 3 – 9 months (except in pregnancy – see section 6.1.3)
There is an increased risk of vitreous haemorrhage associated with acute blood
glucose control.
Severe and repeated hypoglycemia should also be avoided because of the risk of
precipitating vitreous hemorrhage.
6.1.2 c. Pre-Pubertal Type 1 diabetes (IDDM)
Retinopathy is uncommon in young IDDM patients before the age of 12 years old.
Hormonal changes at puberty have an added negative effect on diabetic
retinopathy.
Pre-puberty IDDM with retinopathy should have fairly tight blood glucose control
especially before they enter puberty.
If blood glucose control was not good prior to entering puberty, then control of
blood glucose during puberty must be done gradually over 3 – 9 months period to
avoid deterioration of retinopathy. Severe and repeated hypoglycemia should also
be avoided for similar reasons.
6.1.3 PREGNANCY
Pregnancy is associated with a marked elevation in human placental lactogen
which has many growth-hormone like effects. Other peptide and steroid
hormones, such as estrogen and progesterone, also change markedly during
gestation and have been suggested as predisposing factors in diabetic retinopathy.
The retinopathy in pregnant type 1 diabetes (IDDM) of type 2 diabetes (NIDDM)
patients can worsen during pregnancy.
The course of eye disease during pregnancy is closely related to the severity of
retinopathy at the start of pregnancy.
Retinopathy has been shown to regress spontaneously to some extent after
delivery.
Those patients without retinopathy do not have significant progression and have
relatively uncomplicated pregnancies.
Pregnancy should be planned and normoglycemia achieved over 6 – 8 months
before conception.
Pregnant type 1 diabetes (IDDM) of type 2 diabetes (NIDDM) with retinopathy
and poor control of blood glucose must be managed at a specialist center, by an
obstetrician, diabetologist, endocrinologist and ophthalmologist.
Blood glucose must be brought down to normoglycemia over 2 – 3 weeks to
prevent diabetic fetopathy.
Insulin therapy should be used and OHA should be avoided.
Any acute deterioration of retinopathy must be managed by photocoagulation.
6.2
HYPERTENSION
Since hypertension potentiates diabetic retinopathy, the blood pressure must be
well controlled in a diabetic especially when retinopathy is present.
6.3
PROTEINURIA
Diabetic patients with proteinuria usually signify the presence of microangiopathy
in other target organs like retinopathy and neuropathy.
Renal disease (50% depression of creatinine clearance and proteinuria >
150mg/24hr) appears to be associated with deterioration of retinopathy to a more
severe level.
Blood glucose control should be optimized with insulin regimen in the presence
of significant renal impairment.
Any sight threatening retinopathy that ensues, must be managed with
photocoagulation.
6.4
SMOKING
Cigarette smoking accelerates retinopathy.
Diabetic patients must stop smoking.
6.5
EXERCISE
Aerobic and endurance exercise are recommended in all patients.
In the presence of PPDR/PDR, strenuous and resistance exercise are
contraindicated because these may precipitate vitreous haemorrhage.
6.6
WEIGHT REDUCTION
Overweight diabetic patients should be encouraged to achieve as near to ideal
body weight as possible (except in pregnancy). This improves insulin resistance
and helps to achieve good blood glucose control.
6.7
LIPIDS
Hyperlipidaemia in a diabetic patient should be managed as in the National
Diabetic Consensus. There is no direct evidence for hyperlipidaemia and
microangiopathy.
6.8
ANAEMIA
There is no direct evidence for anaemia and retinopathy, but anaemia results in
increase blood flow and could result in ischaemia.
7.0
RECOMMENDATIONS FOR SCREENING OF DIABETIC RETINOPATHY.
7.1
Based upon the natural history of diabetic retinopathy, it is recommended that
retinal screening be done on all patients aged over 12 years with diabetes mellitus.
The screening examination should be performed on an annual basis and must
include measurement of the visual acuity.
7.2
Every newly diagnosed diabetic patient, visiting the primary care physician,
should have a vision test and fundoscopy at the time of diagnosis and also on an
annual basis.
7.3
Any patient with decreased vision of fundal changes with normal vision of fundus
that cannot be examined must be referred to the ophthalmologist. Subsequent
management and reviews should follow the recommendations as in the Appendix
11 and 111.
7.4
The diabetic patient must be educated about the need for regular fundus
examination. Each patient should possess an ‘diabetic eye care card’ recording the
date and the result of screening. Documentation of the card should be emphasied
to the health care providers.
8.0
CONCLUSION
8.1
Diabetic retinopathy is a common preventable cause of severe visual impairment
and blindness.
8.2
Annual screening for diabetic retinopathy of all patients aged over 12 years is the
only means of preventing loss of sight.
Options for this screening process are described and should be used appropriately.
8.3
Treatment of diabetic retinopathy is generally satisfactory but when necessary.
Should be available in many government hospitals: specialized vitreoretinal
surgery is undertaken in a few centers.
8.4
Aftercare of blind and partially sighted diabetic patients can be improved
substantially by proper use of existing resources.
8.5
A comprehensive programme of screening and treatment requires the creation of
diabetic registers, covering all diabetic patients in each health district.
8.6
Implementation of the recommendations in this guideline has the potential to
improve the future well-being of diabetic patients in Malaysia.
REFERENCES
1.
The DCCT Research Group. The effect of intensive treatment of diabetes on the
development and progression of long-term complications in IDDM. The New
England Joumal of Medicine 329,977 – 986 1993.
2.
Early Treatment Diabetic Retinopathy Study Research Group.
Photocoagulation of diabetic macular oedema. Arch.
Ophthalmo. 103 – 106 1985.
3.
Early Treatment Diabetic Retinopathy Study. Early photocoagulation for diabetic
retinopathy. ETDRS report number 9. Ophthalmology 98 : 766 – 785 1991.
4.
Groop LC., Teir S., Koskimies., et al. Risk factors and markers associated with
proliferative retinopathy in patients with IDDM.
Diabetes. 35 : 1397 1986.
5.
Jovanovic – Peterson L., Peterson CM. Diabetic retinopathy.
Clinical Obstetrics and Gynecology 34 : 516 1991.
6.
Klein R., Klein BEK., Moss SE., David MD., and Demets DL.
The Winconsin Epidemiologic Study of Diabetic Retinopathy II. Prevalence and
risk of Diabetic Retinopathy when age of onset at diagnosis is less than 30yrs.
ARC. Ophthalmo. 102 :520 – 526 1984.
7.
Klein R., Klein BEK., Moss SE., David MD., and Demets DL.
The Winconsin Epidemiologic study of Diabetic Retinopathy III. Prevalence and
risk of Diabetic Retinopathy when age of onset at diagnosis is 30yrs. And more.
ARCH. Ophthalmo. 102 : 527 – 532 1984.
8.
Klein R., Klein BEK., Moss SE., David MD., and Demets DL.
The Winconsin Epidemiologic Study of Diabetic Retinopathy IV
Diabetic macular oedema. Ophthalmology 91 : 1464 – 1474 1984.
9.
Klein R., Klein BEK., Moss SE., David MD., and Demets DL.
Retinopathy in young onset diabetic patients. Diabetes Care. 8 : 311 1985.
10.
Knowler WC., Bennet PH., Ballintine EJ. Increase incidence of diabetic
retinopathy with elevated blood pressure. The New England Journal of Medicine.
302 : 645 1980.
11.
Palmberg P. Smith M. Waltman S. Krupin., et al The natural history of
retinopathy in insulin dependent juvenile onset diabetes. Ophthalmology 88 :
613 – 618 1981.
12.
Rand LI., Krolewski AS., Aiello LM., et al. Multiple factors in the prediction of
risk of diabetic retinopathy. 313 : 1433 1985.
13.
The National Eye Survey 1996 : Preliminary Report – Disease Control division
Ministry of Health.
A QUICK REFERENCE GUIDE
: Duration of diabetes is the
most important correlate of
prevalence and severity of
retinopathy
: No Symptoms of sight
threatening diabetic
retinopathy in its early
stages, when is most
amenable to treatment.
RISK FACTOR
: Uncontrolled
hypertension
: Smoking
: 30% of the
diagnosed diabetic
population has
retinopathy
: and each year 1%
of these develop
sight threatening
retinopathy
DIABETIC EYE DISEASE
The most commonest cause of visual loss in adults of working
age in Malaysia
: In 50%-60% of patients
with maculopathy, vision
will improve by laser
: In 80% of patients with profilative
retinopahty, new vessels will be
abolished by laser treatment
: Prolonged follow up indicates that the
disease is stabilised or effectively cured
: Good control of diabetes prevents onset or
retards progression of retinopathy in young
persons with Type I diabetes
: Screening for diabetic eye disease is shown to
prevent loss of sight
Patients and carers should be made aware of support available
for visually handicapped diabetic patients
Adapted from Scottish Intercollegiate Guideline Network
(Reprinted with permission from Scottish Intercolegiate Guidelines Network.)
APPENDIX I
FLOW CHART FOR DIABETIC RETINOPATHY
DIABETIC PATIENT
VISUAL ACUITY
: NORMAL VISION
: NORMAL FUNDUS
ANNUAL CHECK
REFER TO APPENDIX II
: DECREASE VISION
: FUNDAL CHANGES
: UNABLE TO EXAMINE
FUNDUS
REFER TO
OPHTHALMOLOGIST
NORMAL
FUNDUS
ABNORMAL
FUNDUS
REFER TO APPENDIX III
APPENDIX II
SUGGESTED TIMETABLE FOR DETAILED MEDICAL EYE EXAMINATION
OF PERSONS WITH DIABETES.
Age of onset of
diabetes (years)
Recommended time of first eye
exam.
Routine minimum
Follow-up
0 – 30
Within 5 years of diagnosis
Yearly
31 and older
Upon diagnosis
Yearly
Prior to pregnancy
Prior to conception or early in
first trimester
3 months
Adapter from American Academy of Ophthalmology
(Reprinted with permission from Scottish Intercolegiate Guidelines Network.)
APPENDIX III
Observed retinal abnormality
None or Rare Microaneurysms
Follow-up
Yearly
Mild NPDR
Every 9 months
Moderate NPDR
Every 6 months
Severe NPDR
Every 4 months
Diabetic Retinopathy with Clinically
Significant Macular Edema occurring
at any level of retinopathy
Every 2 – 4 months
(careful follow up)
Proliferative Diabetic Retinopathy
Every 2 – 3 months
NPDR – NonProliferative Diabetic Retinopathy
EYE CARE CARD (SAMPLE)
NAME :
DATE
VISUAL ACUITY
R
Date Of Birth :
Sex :
I/C :
L
FUNDAL EXAM REMARKS & SIGNATURE
R
L