Diabetic Retinal Screening Grading and Referral Guidance 2014 David Squirrell Retinal Screening Steering Group 6 November 2014
Increasing duration of diabetes and poor blood glucose control increases the risk of developing and progression of diabetic retinopathy Other risk factors include hypertension, pregnancy, nephropathy, elevated blood lipids All people with diabetes are at risk of developing retinopathy
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The retinopathy cascade. No DR. Background DR. Referrable Preproliferative DR. disease. Proliferative DR Advanced DR eye disease
Aim: To provide high quality equitable screening to those at risk of eye disease 1. Review the pathways 2. Future proof the model. 3. Develop realistic QA standards $
Aim: To provide high quality equitable screening to those at risk of eye disease 1. Review the pathways 2. Future proof the model. 3. Develop realistic QA standards $
What is new? Reviewing and updating the pathways
Rate of progression of diabetic retinopathy. Rate of progression to: PDR 1 year PDR 5 year Background 2% 10% Low risk NPDR 15% 30% High risk NPDR 30% 75%
1. Predicting Development of Proliferative Diabetic Retinopathy NWANYANWU et al, Diabetes Care 36: 1562- 1568, 2013.
Multivariant progression analysis the absolute 5 year probability of progression to PDR for low risk NPDR (including EDTRS level 20 and 35) was 5%. For high risk individuals it was 37%. A 1% increase in HbA1C was associated with a 14% increase in the risk of progression of retinopathy from NPDR to PDR. Those with non healing ulcers had an astonishing 54% increased risk of developing PDR.
Grade Clinical Outcome No signs Brief description R0 No retinopathy No Type 1: re-screen 2 years . abnormalities Type 2: re-screen at 3 years . Presence of clinical modifiers may require earlier re-screening. (See Table 9, section 7) R1 Minimal < 5 Re-screen 2 years if current HbA1C <53 microaneurys mmol/mol. ms or dot haemorrhages Presence of clinical modifiers may require earlier re-screening.(See Table 9, section 7) . R2 Mild > 4 MA . Rescreen 12 months Exudates . Note: Type 2: interval may be extended to 18 months if current HbA1C is < 53 mmol/mol R3 Moderate Any features Re-screen 6 months. of mild. – If HbA1C > 75 mmol/mol review by • definite • two • Or four • • sub hyaloid • Traction – • definite IRMA • two quadrants or • Or four quadrants of • neovascularisation • sub hyaloid or vitreous haemorrhage • Traction retinal detachment or retinal gliosis.
What is new? • Future proofing the pathways: • Guidance for both screening and monitoring diabetic eye disease.
OCT and Widefield photography
What is new? • Quality assurance standards.
8. Quality assurance requirements “Each screening programme is required to compile an annual report which should be submitted to the local DHB funder. It is suggested that as a bare minimum this report should include the data requirements outlined in Section 10.”
Next steps • The Draft Guidance document is released on Friday 7 November to begin a one month feedback process • Key stakeholders include the diabetes sector, DHBs, PHOs & General Practitioners • Comment will be sought on the screening pathways, grading and format of the document • Following analysis of feedback, finalised guidance will be published early 2015
Any questions? Retinal Screening Guidance Steering Group Gordon Sanderson (Chair), Optometrist, University of Otago, Dunedin Derek Sherwood, Ophthalmologist, Nelson Marlborough DHB David Squirrel, Ophthalmologist, Auckland DHB Mary Jane Sime, Ophthalmologist, Southern DHB John Grylls, Optometrist, Kapiti Olga Brochner, Ophthalmology Clinical Nurse Specialist, Auckland DHB Stephanie Emma, Manager Retinal Screening, Counties Manukau DHB Kirsten Coppell, Public Health Physician, University of Otago, Dunedin
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