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Perspectives in Disease Prevention and Health Promotion Guidelines for Diabetic Eye Disease Control -- Kentucky

Diabetic eye disease is the leading cause of new cases of blindness in the United States in adults 75 years of age. Furthermore, people with diabetes are at increased risk for visual loss due to diabetic retinopathy, glaucoma, and cataracts. Early identification and treatment of diabetic retinopathy can reduce severe visual loss by 60%. Since detection of proliferative eye disease is subtle, it is best performed by persons specially trained in eye disease. However, since patients with retinopathy are usually asymptomatic at the most treatable stage of their disease, they may not seek an examination at that time. For these reasons, policymakers in the state of Kentucky felt that specific guidelines for diabetic eye disease management were necessary. A panel of national and state experts addressed this issue at a meeting sponsored by the diabetes coordinating center of the World Health Organization in Kentucky. Guidelines for Diabetic Eye Disease Control

Eye care for the patient with diabetes requires a partnership between the primary physician, the eye-care specialist, and the patient. The primary care physician not only plays a fundamental role in medical management of the patient, including control of blood glucose and blood pressure, but also assumes responsibility for patient education and coordination of care. Consequently, the primary care physician should be aware of recommendations for ophthalmic care. These guidelines are intended to familiarize all involved health professionals with these needs.

  1. All patients should be informed (a) that sight-threatening eye disease is a common complication of diabetes mellitus and can often be present even with good vision and (b) that early detection and appropriate treatment of diabetic eye disease greatly reduce the risk of visual loss.

  2. Patients with diabetes mellitus should have their first complete eye examination after 5 years duration of diabetes if they are between 10 and 30 years of age or at the time of diagnosis of diabetes if they are over 30 years of age.

  3. This initial eye examination should include a history of visual symptoms, a measurement of visual acuity and intraocular pressure, and an ophthalmoscopic examination through dilated pupils.

  4. After the initial eye examination, persons with diabetes mellitus should receive the above ophthalmic examinations annually unless more or less frequent examinations are indicated by the presence or absence of abnormalities.

  5. It is desirable that any woman who has insulin-dependent diabetes mellitus and who is planning (considering) pregnancy within 12 months should be under the care of an ophthalmologist.

  6. A woman with established diabetes mellitus (diagnosed prior to conception) who becomes pregnant should be examined for retinopathy by an ophthalmologist in the first trimester and thereafter at the discretion of the ophthalmologist.

  7. Patients should be referred to an ophthalmologist promptly for unexplained visual symptoms, reduced corrected visual acuity, increased intraocular pressure, any retinal abnormalities, or any other ocular pathology that threatens vision.

  8. All patients should be under the care of a retinal specialist or other ophthalmologist experienced in the management of diabetic retinopathy when the following conditions are suspected or have been positively identified: Preproliferative retinopathy (multiple cotton-wool spots, multiple intraretinal hemorrhages, intraretinal microvascular abnormalities, or venous beading).

Proliferative retinopathy (retinal neovascularization, preretinal or vitreous hemorrhage, fibrosis, or traction retinal detachment).

Macular edema (hard lipid exudates and/or retinal thickening inside the temporalvascular arcades). 9. Laser photocoagulation therapy is effective in reducing the risk

of visual loss in patients with high-risk proliferative retinopathy and clinically significant macular edema. Vitrectomy can restore vision in certain patients with recent traction retinal detachment and/or vitreous hemorrhage. Laser therapy and vitrectomy should be performed by a retinal specialist or other ophthalmologist experienced in these procedures. 10. Patients with functionally decreased visual acuity should undergo

low vision evaluation and rehabilitation. These guidelines are currently being considered for approval by state and national groups. A task force is developing an implementation plan for Kentucky. Reported by P Allweiss, MD, S Leichter, MD, Kentucky Diabetes Foundation, W Wood, MD, Lexington, C Hernandez, MD, MPH, Dept of Health Svcs, Kentucky Cabinet for Human Resources; Div of Diabetes Control, Center for Preventive Svcs, CDC.

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