eMedicine Specialties > Ophthalmology > Retina

Retinopathy, Diabetic, Background: Follow-up

Author: Abdhish R Bhavsar, MD, Adjunct Assistant Professor, Department of Ophthalmology, University of Minnesota Medical School; Director of Clinical Research, Retina Center, PA; Past Chair, Consulting Staff, Department of Ophthalmology, Phillips Eye Institute
Coauthor(s): John H Drouilhet, MD, FACS, Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine
Contributor Information and Disclosures

Updated: Oct 6, 2009

Follow-up

Further Outpatient Care

  • The frequency of follow-up care is dictated primarily on the baseline stage of the retinopathy and its rate of progression to proliferative diabetic retinopathy (PDR).
    • Only 5% of patients with mild NPDR would progress to PDR in 1 year and, thus, could be monitored every 6-12 months.
    • As many as 27% of patients with moderated NPDR would progress to PDR in 1 year; therefore, they should be seen every 4-8 months.
    • More than 50% of patients with severe NPDR (preproliferative stage) would progress to PDR in a year; thus, follow-up care as frequent as 2-4 months is mandated to ensure prompt recognition and treatment.
    • Any stage associated with clinically significant macular edema (CSME) should be treated and observed closely (every 2-3 mo) to monitor the status of the macula.

Deterrence/Prevention

  • The Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UK-PDS) were large randomized clinical trials that demonstrated the importance of tight glucose control with respect to reducing the incidence and progression of diabetes complications including diabetic retinopathy for both type 1 and type 2 diabetes.13

Complications

  • The complications of focal and grid laser therapy include the following:
    • Decreased central vision
    • Paracentral scotomas
    • Choroidal neovascularization
    • Epiretinal membrane formation
    • Further increase in macular edema

Prognosis

  • The Early Treatment for Diabetic Retinopathy Study (ETDRS) has found that laser surgery for macular edema reduces the incidence of moderate visual loss (doubling of visual angle or roughly a 2-line visual loss) from 30% to 15% over a 3-year period.
  • Favorable prognostic factors
    • Circinate exudates of recent onset
    • Well-defined leakage
    • Good perifoveal perfusion
  • Unfavorable prognostic factors
    • Diffuse edema/multiple leaks
    • Lipid deposition in the fovea
    • Macular ischemia
    • Cystoid macular edema
    • Preoperative vision of less than 20/200
    • Hypertension

Patient Education

  • One of the most important aspects in the management of diabetic retinopathy is patient education. Inform patients that they play an integral role in their own eye care. Emphasize the following facts:
    • Excellent glucose control is beneficial in any stage of diabetic retinopathy. It delays the onset and slows down the progression of the diabetic complications in the eye.
    • Other systemic problems, such as hypertension, renal disease, and hyperlipidemia, may contribute to the progression of the retinopathy and should be addressed promptly.
    • Smoking, although not directly proven to affect the course of the retinopathy, may play a role in further compromising oxygen delivery to the retina. Therefore, all efforts should be made in the reduction, if not outright cessation, of smoking.
    • Visual symptoms (eg, changes in vision, redness, pain) could be manifestations of disease progression and should be reported immediately.
    • DM in general and diabetic retinopathy in particular are progressive conditions such that regular follow-up care with a physician is crucial to detect any changes that may benefit from treatment.
  • For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article Diabetic Eye Disease.

Miscellaneous

Medicolegal Pitfalls

  • Failure to emphasize to the patient that focal or grid laser treatment of clinically significant macular edema (CSME) is not aimed at improving vision but rather at reducing the risk of moderate visual loss.

Special Concerns

  • All individuals with diabetes should be aware of the importance of regular dilated retinal examinations. Early diagnosis and treatment of diabetic retinopathy can help prevent blindness in more than 90% of cases. However, in spite of treatment, sometimes, individuals can still lose vision. The patient, ophthalmologist or retina specialist, and internist or endocrinologist must work together as a team to optimize the diabetes control and help to reduce the risk of blindness.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Sherman O Valero, MD, to the development and writing of this article.



More on Retinopathy, Diabetic, Background

Overview: Retinopathy, Diabetic, Background
Differential Diagnoses & Workup: Retinopathy, Diabetic, Background
Treatment & Medication: Retinopathy, Diabetic, Background
Follow-up: Retinopathy, Diabetic, Background
Multimedia: Retinopathy, Diabetic, Background
References
[ CLOSE WINDOW ]

References

  1. Federman JL, Gouras P, Schubert H, et al. Systemic diseases. In: Podos SM, Yanoff M, eds. Retina and Vitreous: Textbook of Ophthalmology. Vol 9. 1994:7-24.

  2. Aiello LM, Cavallerano JD, Aiello LP, Bursell SE. Diabetic retinopathy. In: Guyer DR, Yannuzzi LA, Chang S, et al, eds. Retina Vitreous Macula. Vol 2. 1999:316-44.

  3. Benson WE, Tasman W, Duane TD. Diabetes mellitus and the eye. In: Duane's Clinical Ophthalmology. Vol 3. 1994.

  4. Frank RN. Etiologic mechanisms in diabetic retinopathy. In: Ryan SJ, ed. Retina. Vol 2. 1994:1243-76.

  5. Crawford TN, Alfaro DV 3rd, Kerrison JB, Jablon EP. Diabetic retinopathy and angiogenesis. Curr Diabetes Rev. Feb 2009;5(1):8-13. [Medline].

  6. Klein R, Knudtson MD, Lee KE, Gangnon R, Klein BE. The Wisconsin Epidemiologic Study of Diabetic Retinopathy XXIII: the twenty-five-year incidence of macular edema in persons with type 1 diabetes. Ophthalmology. Mar 2009;116(3):497-503. [Medline].

  7. Klein R. The Diabetes Control and Complications Trial. In: Kertes C, ed. Clinical Trials in Ophthalmology: A Summary and Practice Guide. 1998:49-70.

  8. Rodriguez-Fontal M, Kerrison JB, Alfaro DV, Jablon EP. Metabolic control and diabetic retinopathy. Curr Diabetes Rev. Feb 2009;5(1):3-7. [Medline].

  9. Liew G, Mitchell P, Wong TY. Systemic management of diabetic retinopathy. BMJ. Feb 12 2009;338:b441. [Medline].

  10. Akduman L, Olk RJ. The early treatment for diabetic retinopathy study. In: Kertes C, ed. Clinical Trials in Ophthalmology: A Summary and Practice Guide. 1998:15-36.

  11. Bhavsar AR. Diabetic retinopathy: the latest in current management. Retina. Jul-Aug 2006;26(6 Suppl):S71-9. [Medline].

  12. Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmology. Sep 2008;115(9):1447-9, 1449.e1-10. [Medline].

  13. Genuth S. The UKPDS and its global impact. Diabet Med. Aug 2008;25 Suppl 2:57-62. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

background diabetic retinopathy, diabetic retinopathy, BDR, diabetic retinopathy treatment, nonproliferative diabetic retinopathy, NPDR, diabetes mellitus, DM, diabetes mellitus retinopathy, DM retinopathy, blindness, vision loss, visual acuity loss, visual loss, diabetic macular edema, DME

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Abdhish R Bhavsar, MD, Adjunct Assistant Professor, Department of Ophthalmology, University of Minnesota Medical School; Director of Clinical Research, Retina Center, PA; Past Chair, Consulting Staff, Department of Ophthalmology, Phillips Eye Institute
Abdhish R Bhavsar, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, and Minnesota Medical Association
Disclosure: Allergan Grant/research funds None; genentech Grant/research funds None; regeneron Grant/research funds None; sirion Grant/research funds None

Coauthor(s)

John H Drouilhet, MD, FACS, Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine
John H Drouilhet, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

V Al Pakalnis, MD, PhD, Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center
V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians & Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.