Diabetic Retinal Screening Grading and Referral Guidance 2014 David - - PowerPoint PPT Presentation

Diabetic Retinal Screening Grading and Referral Guidance 2014

David Squirrell Retinal Screening Steering Group 6 November 2014

Increasing duration of diabetes and poor blood glucose control increases the risk of developing and progression of diabetic retinopathy Other risk factors include hypertension, pregnancy, nephropathy, elevated blood lipids All people with diabetes are at risk of developing retinopathy

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The retinopathy cascade.

No DR. Background DR. Preproliferative DR. Proliferative DR Advanced DR eye disease

Referrable disease.

Aim: To provide high quality equitable screening to those at risk of eye disease

• 1. Review the pathways
• 2. Future proof the model.
• 3. Develop realistic QA standards

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Aim: To provide high quality equitable screening to those at risk of eye disease

• 1. Review the pathways
• 2. Future proof the model.
• 3. Develop realistic QA standards

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Reviewing and updating the pathways

What is new?

Rate of progression to: PDR 1 year PDR 5 year Background 2% 10% Low risk NPDR 15% 30% High risk NPDR 30% 75%

Rate of progression of diabetic retinopathy.

• 1. Predicting Development of

Proliferative Diabetic Retinopathy

NWANYANWU et al, Diabetes Care 36: 1562- 1568, 2013.

Multivariant progression analysis the absolute 5 year probability of progression to PDR for low risk NPDR (including EDTRS level 20 and 35) was 5%. For high risk individuals it was 37%. A 1% increase in HbA1C was associated with a 14% increase in the risk of progression of retinopathy from NPDR to PDR. Those with non healing ulcers had an astonishing 54% increased risk of developing PDR.

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• definite IRMA
• two quadrants or
• Or four quadrants of
• neovascularisation
• sub hyaloid or vitreous haemorrhage
• Traction retinal detachment or retinal gliosis.

Grade Brief description Clinical signs Outcome No

R0 No retinopathy No abnormalities Type 1: re-screen 2 years. Type 2: re-screen at 3 years. Presence of clinical modifiers may require earlier re-screening. (See Table 9, section 7) R1 Minimal < 5 microaneurys ms or dot haemorrhages Re-screen 2 years if current HbA1C <53 mmol/mol. Presence of clinical modifiers may require earlier re-screening.(See Table 9, section 7) . R2 Mild > 4 MA . Exudates . Rescreen 12 months Note: Type 2: interval may be extended to 18 months if current HbA1C is < 53 mmol/mol R3 Moderate Any features

• f mild.

Re-screen 6 months. If HbA1C > 75 mmol/mol review by –

• definite
• two
• Or four
• sub hyaloid
• Traction

• Future proofing the pathways:
• Guidance for both screening and monitoring

diabetic eye disease.

What is new?

OCT and Widefield photography

• Quality assurance standards.

What is new?

 8. Quality assurance requirements  “Each screening programme is required to compile an annual report which should be submitted to the local DHB funder. It is suggested that as a bare minimum this report should include the data requirements outlined in Section 10.”

• The Draft Guidance document is released on Friday 7

November to begin a one month feedback process

• Key stakeholders include the diabetes sector, DHBs,

PHOs & General Practitioners

• Comment will be sought on the screening pathways,

grading and format of the document

• Following analysis of feedback, finalised guidance will

be published early 2015

Next steps

Retinal Screening Guidance Steering Group

Gordon Sanderson (Chair), Optometrist, University of Otago, Dunedin Derek Sherwood, Ophthalmologist, Nelson Marlborough DHB David Squirrel, Ophthalmologist, Auckland DHB Mary Jane Sime, Ophthalmologist, Southern DHB John Grylls, Optometrist, Kapiti Olga Brochner, Ophthalmology Clinical Nurse Specialist, Auckland DHB Stephanie Emma, Manager Retinal Screening, Counties Manukau DHB Kirsten Coppell, Public Health Physician, University of Otago, Dunedin

Any questions?