Philip Anderton BOptom PhD Visiting Optometrist Manilla Health Service HNEAHS

1. Confirm regular general diabetic program and Blood Glucose monitoring/control 2. Best corrected visual acuity Needs refraction to ddx refractive error vs Clinically Significant Macula Edema (CSME) 3. Intraocular pressures and assess other risk factors for glaucoma 4. Dilated fundus examination Non-Proliferative Diabetic Retinopathy (NPDR) Proliferative Diabetic Retinopathy (PDR) CSME 5. Report to GP and diabetes team Medicare Schedule Item

 Ophthalmoscopy Pupil Dilation is ESSENTIAL Mydriacyl 0.5% or 1.0%; Phenylephrine 1.0% Direct Ophthalmoscopy  small field of vision, high magnification – good for macula and optic disc but difficult to explore complete retina and no stereo view Stereoscopic Biomicroscopy (Indirect)  slit-lamp microscope and 78D or 90D lens is the GOLD STANDARD (NH&MRC Guidelines, 2008)  Retinal camera Non-Mydriatic Digital Retinal Camera  much better than no retinal examination at all  reveals overt macula and disc problems (central 45 deg)  misses peripheral problems and mild/early macula edema  older eyes have small pupils and hazy lenses

 Microvascular pathology in the central retinal vessels Non-Proliferative Diabetic Retinopathy (NPDR)  Capillary aneurism – microaneurism (Ma)  Capillary anomalies - Intraretinal microvascular anomalies (IRMA)  Capillary leak  Diabetic macular oedema and exudate (Clinically Significant Macula Edema - CSME)  Ischemic neuropathy ganglion cell axons (Cotton wool spots - CWS)  Intraretinal bleeding – haemorrhage  Venous beading (VB) Proliferative Diabetic Retinopathy (PDR)  Neovascularization  Fragile new vessels proliferating over the retinal surface  Early PDR is treatable with laser oblation  Late PDR is potentially blinding with poor treatment options

 Diabetic cataract  Neovascularisation of the iris Iris rubeosis neovascular glaucoma

 20 yo male, Type 1 IDDM 5 years diagnosed  Medication- Actrapid penfill Coversyl Glucagon and Protaphane  Best corrected VA R: 6/7.5 L: 6/15 **

1. No apparent retinopathy 2. Mild NPDR Ma only 3. Moderate NPDR More than just Ma but less than severe NPDR 4. Severe NPDR More than 20 intraretinal haems in each of 4 quadrants, definite venous beading in 2 or more quadrants, prominent IRMA in one or more quadrant and no sign of PDR 5. PDR Neovascularization Neovascularization and vitreous preretinal haems

 For every diabetic If no known retinal pathology, examine every 24 months If mild (background, NPDR) retinal pathology, examine every 12 months, refer as appropriate If PDR and/or CSME, refer for assessment and treatment  Treatment options –  Retinal/ macula Laser  Intravitreal anti-VEGF injections