1. I NTEGRATED CARE B ASED ON THE G UIDELINES FOR PATIENTS WITH DIABETIC RETINOPATHY By Yanira I. Marrero McFaline MD

2. O BJECTIVES Discuss the American Diabetes Association and the American Academy of Ophtalmology Guidelines for management and care of DR. Describe when examine patients with type 1 and type 2 diabetes, and diabetes during pregnancy. Importance of integrated care in patients. Overall of treatment for DR.

4. ADA GUIDELINES Diabetic retinopathy is a highly specific vascular complication of type 1 and type 2 diabetes. Prevalence related to both duration and the level of glycemic control DR is the most frequent cause of new cases of blindness among adults aged 20-74 years in developed countries Glaucoma, cataracts, and other disorders occur earlier.

5. ADA GUIDELINES Factors that increase the risk or are associated with retinopathy Diabetes duration Chronic hyperglycemia Nephropathy Hypertension Dyslipidemia Intensive diabetes management has been shown in large prospective randomized studies to prevent and/or delay the onset and progression of diabetic retinopathy.

6. ADA GUIDELINES Lowering BP decrease retinopathy progression. Tight targets (systolic < 120 mmHg) do not impart additional benefit. In patients with dyslipidemia, DR progression may be slowed by the addition of fenofibrate, particularly with very mild nonproliferative diabetic retinopathy at baseline.

7. ADA GUIDELINES Pregnancy in patients with type 1 diabetes may aggravate retinopathy especially when glycemic control is poor at the time of conception. Laser photocoagulation surgery can minimize the risk of vision loss

8. S CREENING An ophtalmologist or optometrist who is knowledgeable and experienced in diagnosing diabetic retinopathy should perform the examination. If retinopathy present, referral to ophtalmologist. Subsequent examinations are generally repeated annually for patients with minimal or no retinopathy.

9. S CREENING Exams each 2 years may be cost-effective after one or more normal eye exams. Population with well controlled type 2 diabetes Examinations will be more frequent if retinopathy is progressing. Retinal photography with remote reading by experts Great potential in areas where qualified eye care professionals are not available

10. S CREENING Interpretation of the images should be performed by a trained eye care provider. In person exams are still necessary when the photos are not acceptable and for follow-up if abnormalities detected. Retinal photos are not a substitute for a comprehensive eye exam Should be perfomed initially and at intervals thereafter as recommended by an eye care professional Results should be documented and transmitted to the referring health care professional.

11. T YPE 1 D IABETES Retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia Patient with type 1 diabetes should have an initial dilated and comprehensive exam within 5 years after the diagnosis of diabetes.

12. T YPE 2 D IABETES Patients with type 2 diabetes who may have had years of undiagnosed diabetes and have a significant risk of prevalent diabetic retinopathy at the time of diagnosis should have an initial dilated and comprehensive eye examination at the time of diagnosis.

13. P REGNANCY Rapid progression of diabetic retinopathy. Counseling to patients with type 1 or 2 diabetes who wants to become pregnant or are pregnant Risk of development or progression Gestational diabetes Do not require an eye examination during pregnancy Not increased risk of developing diabetic retinopathy during pregnancy.

14. T REATMENT Main motivations for screening for diabetic retinopathy are to prevent vision loss and to intervene with treatment when vision loss can be prevented or reversed Photocoagulation surgery Antivascular Endothelial Growth Factor Treatment More effective regimen for center involved diabetic macular edema

16. C ARE P ROCESS Medical history Regular ophtalmologic examination or screening of high-quality retinal photographs of patients with no previous treatment for retinopathy Regular follow up Effective screening Who needs referral to ophtalmologist

17. C ARE PROCESS Early detection of retinopathy depends of educating patient with diabetes, family, health care providers about the importance of regular eye examination, even if no symptoms are present. Type 1 diabetes: annual dilated eye examination beginning 5 years after the onset of diabetes. Type 2 diabetes: annual dilated exam.

19. C ARE P ROCESS Near normal glucose levels and near normal blood pressure levels Lowers the risk of retinopathy developing and/or progression Good A1C, serum lipids, and blood pressure.

20. C ARE P ROCESS Patient outcome criteria Improvement or stabilization of visual function Improvement or stabilization of vision-related quality of life Optimal control of glucose, blood pressure, and other risk factors through close communication with the patient’s primary care physician regarding the status of the diabetic retinopathy and the need for optimal metabolic control.

21. D IABETES ASSOCIATED WITH PREGNANCY Patients with diabetes who plan to become pregnant Opthtalmologic examination prior to pregnancy Counseling about the risk of progression First trimester Eye examination with follow-up visits depending of severity of retinopathy Both eyes should be classified according to the categories of diabetic retinopathy and macular edema. The diagnostic category and the level of diabetes control determines the timing for both intervention and follow up exam.

22. M ANAGEMENT The visual complications of diabetes can at least be moderated by a healthy lifestyle. Treatment is believed to yield a substantial cost savings when compared with direct costs for individual disabled by vision loss. National Committee for Quality Assurance’s Health Plan Employers Data Information Set System Slow but definite trend toward improving rates of screening examinations and blood glucose control.

23. M ANAGEMENT Still screening rates remain lower than ideal in spite of evidence supporting the effectiveness of treatment Prevention and Early Detection of Diabetic Retinopathy Treatment for diabetic retinopathy may be 90% effective in preventing severe vision loss (visual acuity <5/200) According to guidelines by the American Diabetes Association and the American Academy of Ophtalmology fewer patients with diabetes are referred for ophtalmic care than would be expected

24. P REVENTION The purpose of an effective screening program for diabetic retinopathy is to determine who needs to be referred to an ophtalmologist for close follow- up and treatment and who may simply be screened annually. Some studies have shown that screening programs using digital retinal images taken with or without dilation may enable early detection of diabetic retinopathy along with an appropriate referral.

25. S ECONDARY P REVENTION The DCCT showed that the development and progression of diabetic retinopathy in patients with diabetes type 1 can be delayed when the HbA1c is optimized. Educate patients with diabetes as well as their PCP about the ophtalmologic implications of controlling blood glucose to as near normal as is safely possible.

26. S ECONDARY P REVENTION Blood glucose, lipid levels, and blood pressure. Aspirin therapy at a dose of 650 mg per day does not slow the progression of diabetic retinopathy. Aspirin therapy did not cause more severe, more frequent, or longer-lasting vitreous hemorrhages in patients with PDR. Neither helpful nor harmful in the management of diabetic retinopathy.

27. S ECONDARY PREVENTION ADA recommends Aspirin (75 to 162 mg) Secondary prevention- diabetic patients with history MI, vascular bypass, stroke or TIA, PVD, claudication, or angina. Primary prevention- diabetes at increased cardiovascular risk (10-year risk > 10 percent)- men or women more 50 years with at least one additional cardiovascular risk factor (eg. Cigarette, hypertension, obesity, albuminuria, dyslipidemia, or a family history of CHD). The ADA recognizes that the evidence to support this is weak.

28. S ECONDARY PREVENTION Aspirin is not recommended for CVD prevention for adults with diabetes at low risk, such women and men with 50 years or less with no major additional risk factors. For adults < 50 years with diabetes who have multiple other CV risk factors, clinical judgement is required.

29. C ONCLUSION

30. The prevalence of diabetes worldwide is increasing; such as the prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy. Only about 60% of people with diabetes have yearly screening for diabetic retinopathy. People with Type 1 diabetes should have annual screening beginning 5 years after the onset of their diabetes, whereas those with type 2 diabetes should have a prompt examination at the time of diagnosis and at least yearly examination thereafter.

31. C ONCLUSION Maintaining near-normal glucose levels and near-normal blood pressure lowers the risk of retinopathy developing and/or progressing. Patients with diabetes may use aspirin for other medical indications without an adverse effect on their risk of diabetic retinopathy. In gestational diabetes is not required an eye examination during pregnancy. However, patients with diabetes who become pregnant should be examined early in the course of the pregnancy.

32. C ONCLUSION Referral to an ophtalmologist is required when there is any nonproliferative diabetic retinopathy, proliferative retinopathy, or macular edema. Ophtalmologists should communicate findings and level of retinopathy to the primary care physician. They should emphasize to the patient the need to adhere to the PCP’s guidance to optimize metabolic control.

33. C ONCLUSION Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents- effective treatment for center-involving diabetic macular edema and also as an alternative therapy for proliferative diabetic retinopathy. Laser photocoagulation remains the preferred treatment for non-center-involving diabetic macular edema.