Definitions for the strength of evidence (A–D) and strength of recommendations (A–D) are presented at the end of the "Major Recommendations" field.
Note: 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.
Diagnosis of Ocular Complications of Diabetes Mellitus
Individuals with Undiagnosed 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 noted in the original guideline document.
*Refer to the Optometric Clinical Practice Guideline for Comprehensive Adult Eye and Vision Examination .
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.
Individuals with Diagnosed Diabetes Mellitus
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 .
Patients should be questioned about the awareness of their personal diabetes ABCs (A1C, blood pressure, and cholesterol levels and their history of smoking).
The initial ocular examination should include, but is not limited to, the following evaluations:
- Review of patient medical history
- Best-corrected visual acuity
- Pupillary reflexes
- Ocular motility
- Refractive status
- Confrontation visual field testing or visual field evaluation
- Slit lamp biomicroscopy
- Dilated retinal examination
Dilated Retinal Examination
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 individual's primary care physician should be informed of eye examination results following each examination, even when retinopathy is minimal or not present.
Ocular Examination Schedule
Persons with Diabetes Mellitus
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 (American Diabetes Association, 2013).
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.
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.
Persons with Non-retinal Ocular Complications of Diabetes Mellitus
Examination of persons with non-retinal ocular complications of diabetes should be consistent with current recommendations of care for each condition.
Persons with Retinal Complications of Diabetes Mellitus
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.
Treatment and Management
Management of Ocular Complications of Diabetes Mellitus
Basis for Treatment
Persons with Non-retinal Ocular Complications
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.
As part of the proper management of diabetes, the optometrist should make referrals for concurrent care when indicated.
Treatment of Retinal Complications
Non-proliferative Diabetic Retinopathy (NPDR)
Panretinal photocoagulation (PRP) may be considered in patients with severe or very severe 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 of retinopathy) (Mohamed, Ross, & Chu, 2011). (A/A)
Proliferative Diabetic Retinopathy
Patients with high-risk PDR should receive referral to an ophthalmologist experienced in the management of diabetic retinal disease for prompt scatter PRP (Early Treatment Diabetic Retinopathy Study Research Group [ETDRS], 1991; Chew et al., 2003). (A/A; B/B)
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 (ETDRS, 1991; Chew et al., 2003). (A/A; B/B)
Following successful treatment with PRP, patients should be re-examined every 2 to 4 months. The follow-up interval may be extended based on disease severity and stability.
Diabetic Macular Edema (DME)
Following focal photocoagulation for DME, re-examination should be scheduled in 3 to 4 months.
Patients with center-involved DME should be referred to an ophthalmologist experienced in the management of diabetic retinal disease for possible treatment.
Individuals with 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-vascular endothelial growth factor (VEGF) injection is indicated (Mohamed, Ross, & Chu, 2011). (A/A)
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.
Vascular Endothelial Growth Factor Inhibitors
The current standard of care for treatment of center-involved DME in persons with best corrected visual acuity of 20/32 or worse, is anti-VEGF injections (Diabetic Retinopathy Clinical Research Network, 2008; Diabetic Retinopathy Clinical Research Network et al., 2010). (A/A)
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 be advised of the risks of smoking related to diabetes and encouraged to quit smoking and/or seek smoking cessation assistance.
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 Co-morbidities 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 (American Diabetes Association, 2013).
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 (Knopp et al., 2006). (B/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 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 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.
Strength of Evidence
||Strength of Evidence
||Data derived from well-designed, multiple randomized clinical trials, meta-analyses (systematic review) or diagnostic studies of relevant populations.
Randomized control trials (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.
Strength of Recommendations
||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.