Produção Nacional
Revisado por pares
Guidelines on Diabetic Eye Care
2018; Elsevier BV; Volume: 125; Issue: 10 Linguagem: Inglês
10.1016/j.ophtha.2018.04.007
ISSN1549-4713
AutoresTien Yin Wong, Jennifer K. Sun, Ryo Kawasaki, Paisan Ruamviboonsuk, Neeru Gupta, Van Charles Lansingh, Maurício Maia, Wanjiku Mathenge, Sunil Moreker, Mahiul M. K. Muqit, Serge Resnikoff, Juan Verdaguer, Peiquan Zhao, Frederick L. Ferris, Lloyd Paul Aiello, Hugh R. Taylor,
Tópico(s)Chronic Kidney Disease and Diabetes
ResumoDiabetes mellitus (DM) is a global epidemic and affects populations in both developing and developed countries, with differing health care and resource levels. Diabetic retinopathy (DR) is a major complication of DM and a leading cause of vision loss in working middle-aged adults. Vision loss from DR can be prevented with broad-level public health strategies, but these need to be tailored to a country’s and population’s resource setting. Designing DR screening programs, with appropriate and timely referral to facilities with trained eye care professionals, and using cost-effective treatment for vision-threatening levels of DR can prevent vision loss. The International Council of Ophthalmology Guidelines for Diabetic Eye Care 2017 summarize and offer a comprehensive guide for DR screening, referral and follow-up schedules for DR, and appropriate management of vision-threatening DR, including diabetic macular edema (DME) and proliferative DR, for countries with high- and low- or intermediate-resource settings. The guidelines include updated evidence on screening and referral criteria, the minimum requirements for a screening vision and retinal examination, follow-up care, and management of DR and DME, including laser photocoagulation and appropriate use of intravitreal anti–vascular endothelial growth factor inhibitors and, in specific situations, intravitreal corticosteroids. Recommendations for management of DR in patients during pregnancy and with concomitant cataract also are included. The guidelines offer suggestions for monitoring outcomes and indicators of success at a population level. Diabetes mellitus (DM) is a global epidemic and affects populations in both developing and developed countries, with differing health care and resource levels. Diabetic retinopathy (DR) is a major complication of DM and a leading cause of vision loss in working middle-aged adults. Vision loss from DR can be prevented with broad-level public health strategies, but these need to be tailored to a country’s and population’s resource setting. Designing DR screening programs, with appropriate and timely referral to facilities with trained eye care professionals, and using cost-effective treatment for vision-threatening levels of DR can prevent vision loss. The International Council of Ophthalmology Guidelines for Diabetic Eye Care 2017 summarize and offer a comprehensive guide for DR screening, referral and follow-up schedules for DR, and appropriate management of vision-threatening DR, including diabetic macular edema (DME) and proliferative DR, for countries with high- and low- or intermediate-resource settings. The guidelines include updated evidence on screening and referral criteria, the minimum requirements for a screening vision and retinal examination, follow-up care, and management of DR and DME, including laser photocoagulation and appropriate use of intravitreal anti–vascular endothelial growth factor inhibitors and, in specific situations, intravitreal corticosteroids. Recommendations for management of DR in patients during pregnancy and with concomitant cataract also are included. The guidelines offer suggestions for monitoring outcomes and indicators of success at a population level. Diabetic mellitus (DM) is a global epidemic with significant morbidity and mortality, affecting not only populations in highly developed countries such as the United States, the United Kingdom, and those of Western Europe, but increasingly also developing countries, including China, India, South America, and Africa.1Chan J.C. Malik V. Jia W. et al.Diabetes in Asia: epidemiology, risk factors, and pathophysiology.JAMA. 2009; 301: 2129-2140Crossref PubMed Scopus (1503) Google Scholar, 2Shaw J.E. Sicree R.A. Zimmet P.Z. Global estimates of the prevalence of diabetes for 2010 and 2030.Diabetes Res Clin Pract. 2010; 87: 4-14Abstract Full Text Full Text PDF PubMed Scopus (5012) Google Scholar, 3Werfalli M. Engel M.E. Musekiwa A. et al.The prevalence of type 2 diabetes among older people in Africa: a systematic review.Lancet Diabetes Endocrinol. 2016; 4: 72-84Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 4Yoon K.H. Lee J.H. 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Mathers C.D. Adam T. et al.The burden and costs of chronic diseases in low-income and middle-income countries.Lancet. 2007; 370: 1929-1938Abstract Full Text Full Text PDF PubMed Scopus (1011) Google Scholar, 9Beran D. Yudkin J.S. Diabetes care in sub-Saharan Africa.Lancet. 2006; 368: 1689-1695Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar, 10Mbanya J.C. Motala A.A. Sobngwi E. et al.Diabetes in sub-Saharan Africa.Lancet. 2010; 375: 2254-2266Abstract Full Text Full Text PDF PubMed Scopus (438) Google Scholar Diabetic retinopathy (DR) is a common and specific microvascular complication that develops over time.11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Severe stages of DR, including proliferative dR (PDR) and diabetic macular edema (DME),11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar result in visual impairment and blindness without treatment. Epidemiologic studies have shown that approximately 1 in 3 persons with DM has DR, and 1 in 10 has PDR or DME.12Wong T.Y. Klein R. Islam F.M. et al.Diabetic retinopathy in a multi-ethnic cohort in the United States.Am J Ophthalmol. 2006; 141: 446-455Abstract Full Text Full Text PDF PubMed Scopus (473) Google Scholar, 13Zhang X. Saaddine J.B. Chou C.F. et al.Prevalence of diabetic retinopathy in the United States, 2005–2008.JAMA. 2010; 304: 649-656Crossref PubMed Scopus (762) Google Scholar, 14Yau J.W. Rogers S.L. Kawasaki R. et al.Global prevalence and major risk factors of diabetic retinopathy.Diabetes Care. 2012; 35: 556-564Crossref PubMed Scopus (2746) Google Scholar, 15Mathenge W. Bastawrous A. Peto T. et al.Prevalence and correlates of diabetic retinopathy in a population-based survey of older people in Nakuru, Kenya.Ophthal Epidemiol. 2014; 21: 169-177Crossref PubMed Scopus (22) Google Scholar Based on these rates, between 100 million and 120 million people have DR and possibly 20 million to 30 million have PDR or DME. However, of concern is that population surveys consistently show that half of persons with DM remain undiagnosed16Beagley J. Guariguata L. Weil C. Motala A.A. Global estimates of undiagnosed diabetes in adults.Diabetes Res Clin Pract. 2014; 103: 150-160Abstract Full Text Full Text PDF PubMed Scopus (353) Google Scholar, 17Zhang X. Geiss L.S. Cheng Y.J. et al.The missed patient with diabetes: how access to health care affects the detection of diabetes.Diabetes Care. 2008; 31: 1748-1753Crossref PubMed Scopus (48) Google Scholar, 18Gakidou E. Mallinger L. Abbott-Klafter J. et al.Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys.Bull World Health Organ. 2011; 89: 172-183Crossref PubMed Scopus (102) Google Scholar and that many are unaware of their risk of DR and other complications.19Bressler N.M. Varma R. Doan Q.V. et al.Underuse of the health care system by persons with diabetes mellitus and diabetic macular edema in the United States.JAMA Ophthalmol. 2014; 132: 168-173Crossref PubMed Scopus (63) Google Scholar There are highly effective and cost-effective treatments for PDR and DME, demonstrated over 3 decades with landmark randomized clinical trials that show up to 98% of the blindness could be prevented by timely treatment with laser photocoagulation therapy and vitrectomy surgery,20Ferris 3rd, F.L. How effective are treatments for diabetic retinopathy?.JAMA. 1993; 269: 1290-1291Crossref PubMed Scopus (316) Google Scholar and, in the past decade, intraocular injections of anti–vascular endothelial growth factor (VEGF) inhibitors for DME.11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 21Cheung N. Mitchell P. Wong T.Y. Diabetic retinopathy.Lancet. 2010; 376: 124-136Abstract Full Text Full Text PDF PubMed Scopus (1912) Google Scholar There is also evidence that intravitreal injections of corticosteroids may be useful for DME management, particularly in eyes with previous cataract surgery.11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 22Antonetti D.A. Klein R. Gardner T.W. Diabetic retinopathy.N Engl J Med. 2012; 366: 1227-1239Crossref PubMed Scopus (1156) Google Scholar These treatments, coupled with the concept of earlier detection and systemic management of DM, such as intensive glucose and blood pressure control, have led to observations of declining rates of vision loss resulting from DR in the United States, Western Europe, and many countries over time.23Klein R. Knudtson M.D. Lee K.E. et al.The Wisconsin Epidemiologic Study of Diabetic Retinopathy XXIII: the twenty-five-year incidence of macular edema in persons with type 1 diabetes.Ophthalmology. 2009; 116: 497-503Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar, 24Ting D.S. Cheung G.C. Wong T.Y. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review.Clin Exp Ophthalmol. 2016; 44: 260-277Crossref PubMed Scopus (489) Google Scholar From a public health perspective, vision loss resulting from DR can be prevented with a broad-based systems-level approach: first, by increasing public knowledge with targeted health care education; second, by well-implemented community-level or national screening programs for all persons with DM; third, with timely referral for more severe levels of DR; and finally, with appropriate treatment for advanced DR such as PDR and DME.25Wong T.Y. Mwamburi M. Klein R. et al.Rates of progression in diabetic retinopathy during different time periods: a systematic review and meta-analysis.Diabetes Care. 2009; 32: 2307-2313Crossref PubMed Scopus (147) Google Scholar, 26The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group.N Engl J Med. 1993; 329: 977-986Crossref PubMed Scopus (22708) Google Scholar, 27Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group.Lancet. 1998; 352: 837-853Abstract Full Text Full Text PDF PubMed Scopus (18950) Google Scholar Although such broad public health programs based on best evidence have been, or could be, implemented in high-income countries with the necessary health care structure and resources in terms of funding, trained health care manpower, appropriate medications, and diagnostic and surgical facilities (i.e., in high-resource settings),28Fong D.S. Aiello L.P. Ferris 3rd, F.L. Klein R. Diabetic retinopathy.Diabetes Care. 2004; 27: 2540-2553Crossref PubMed Scopus (525) Google Scholar, 29Javitt J.C. Aiello L.P. Cost-effectiveness of detecting and treating diabetic retinopathy.Ann Intern Med. 1996; 124: 164-169Crossref PubMed Google Scholar, 30Rohan T.E. Frost C.D. Wald N.J. Prevention of blindness by screening for diabetic retinopathy: a quantitative assessment.BMJ. 1989; 299: 1198-1201Crossref PubMed Scopus (119) Google Scholar they remain a substantial challenge for countries with low or intermediate resources.24Ting D.S. Cheung G.C. Wong T.Y. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review.Clin Exp Ophthalmol. 2016; 44: 260-277Crossref PubMed Scopus (489) Google Scholar In these latter countries and communities, the shortage of trained eye care professionals, including ophthalmologists or optometrists, the lack of equipment (e.g., fundus cameras, lasers) and drugs, and poorly structured health care policies limit what can be achieved based on current evidence.31Resnikoff S. Felch W. Gauthier T.M. Spivey B. The number of ophthalmologists in practice and training worldwide: a growing gap despite more than 200,000 practitioners.Br J Ophthalmol. 2012; 96: 783-787Crossref PubMed Scopus (214) Google Scholar, 32Burgess P.I. Msukwa G. Beare N.A. Diabetic retinopathy in sub-Saharan Africa: meeting the challenges of an emerging epidemic.BMC Med. 2013; 11: 157Crossref PubMed Scopus (40) Google Scholar For example, intraocular anti-VEGF agents now are used widely for DME in countries with high-resource settings, but in low- or intermediate-resource settings, the access, availability, and administration of anti-VEGF agents are erratic and may be financially unsustainable, although they have been included in the World Health Organization List of Essential Medicines.33World Health OrganizationWHO model list of essential medicines.http://www.who.int/medicines/publications/essentialmedicines/EML_2015_FINAL_amended_NOV2015.pdf?ua=1Google Scholar Importantly, in many countries, the standard care pathway for DR is not always clear. Most available evidence-based guidelines for DR management are based on very country-specific requirements, and typically only those in a high-resources setting.34Hooper P. Boucher M.C. Colleaux K. et al.Contemporary management of diabetic retinopathy in Canada: from guidelines to algorithm guidance.Ophthalmologica. 2014; 231: 2-15Crossref PubMed Scopus (9) Google Scholar, 35Mohamed Q. Gillies M.C. Wong T.Y. Management of diabetic retinopathy: a systematic review.JAMA. 2007; 298: 902-916Crossref PubMed Scopus (669) Google Scholar, 36Solomon S.D. Chew E. Duh E.J. et al.Diabetic retinopathy: a position statement by the American Diabetes Association.Diabetes Care. 2017; 40: 412-418Crossref PubMed Scopus (453) Google Scholar Some are specific to one aspect of DR care, such as management of DME.37Bandello F. Midena E. Menchini U. Lanzetta P. Recommendations for the appropriate management of diabetic macular edema: light on DME survey and consensus document by an expert panel.Eur J Ophthalmol. 2016; 26: 252-261Crossref PubMed Scopus (9) Google Scholar, 38Das T. Aurora A. Chhablani J. et al.Evidence-based review of diabetic macular edema management: consensus statement on Indian treatment guidelines.Indian J Ophthalmol. 2016; 64: 14-25Crossref PubMed Scopus (15) Google Scholar, 39Mitchell P. Wong T.Y. Diabetic Macular Edema Treatment Guideline Working GroupManagement paradigms for diabetic macular edema.Am J Ophthalmol. 2014; 157: 505-513.e501–e508Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Few comprehensive guidelines are available in low- or intermediate-resource countries.40Rajavi Z. Safi S. Javadi M.A. et al.Diabetic retinopathy clinical practice guidelines: customized for Iranian population.J Ophthalmic Vis Res. 2016; 11: 394-414Crossref PubMed Scopus (8) Google Scholar, 41Ziemssen F. Lemmen K. Bertram B. et al.National guidelines for treatment of diabetic retinopathy: second edition of the national guidelines for treatment of diabetic retinopathy.Ophthalmologe. 2016; 113: 623-638Crossref PubMed Scopus (0) Google Scholar A recent survey of 50 Asian countries showed that only 11 have some form of guidelines, of which 9 pertain to general DM care and only 2 are specific to DR.42Wang L.Z. Cheung C.Y. Tapp R.J. et al.Availability and variability in guidelines on diabetic retinopathy screening in Asian countries.Br J Ophthalmol. 2017; 101: 1352-1360Crossref PubMed Scopus (47) Google Scholar Thus, a recurring problem that health care providers and policy makers face is the lack of clear understanding and guidance within a resource-specific context to design policies, to structure programs, and to monitor for success in implementation. In contrast, there are resource-specific guidelines on management of other major diseases, such as cancer and cardiovascular diseases.43Institute of Medicine (US) Committee on Cancer Control in Low- and Middle-Income Countries.in: Sloan F.A. Gelband H. Cancer Control Opportunities in Low- and Middle-Income Countries. National Academies Press (US), Washington (DC)2007Google Scholar, 44Owolabi M. Miranda J.J. Yaria J. Ovbiagele B. Controlling cardiovascular diseases in low and middle income countries by placing proof in pragmatism.BMJ Global Health. 2016; 1 (pii: e000105. eCollection 2016)Crossref PubMed Scopus (36) Google Scholar, 45Yip C.H. Anderson B.O. The Breast Health Global Initiative: clinical practice guidelines for management of breast cancer in low- and middle-income countries.Expert Rev Anticancer Ther. 2007; 7: 1095-1104Crossref PubMed Scopus (28) Google Scholar To address this critical gap from a global perspective, in 2013, the International Council of Ophthalmology (ICO)46International Council of OphthalmologyICO guidelines for diabetic eye care.http://www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare.pdfGoogle Scholar initiated and developed guidelines based on best evidence from clinical data, incorporating practical real-world clinical experience from different countries and stakeholders. The aim of the 2013 ICO Guidelines for Diabetic Eye Care was to propose a feasible, sustainable, cost-effective set of recommendations for management of DR47International Council of OphthalmologyICO guidelines for diabetic eye care: available in English, Chinese, French, Portuguese, Serbian, Spanish, and Vietnamese.http://www.icoph.org/resources/309/ICO-Guidelines-for-Diabetic-Eye-Care-available-in-English-Chinese-French-Portuguese-Serbian-Spanish-and-Vietnamese.htmlGoogle Scholar with considerations for resource-based setting(s). The ICO consulted widely with ophthalmologists, physicians, and public health professionals with diverse experience and expertise from different nationalities and regions to design the 2013 guidelines, which were disseminated first in 2014. The 2013 guidelines have been translated into 7 languages. These were updated in 2017 as the ICO Guidelines for Diabetic Eye Care.46International Council of OphthalmologyICO guidelines for diabetic eye care.http://www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare.pdfGoogle Scholar This report summarizes the 2017 guideline recommendations for management for DR in both high-resource and low- or intermediate-resource settings, with a specific focus on screening, referral, follow-up, and timely treatment. Specific and detailed management of DR, including PDR and DME, is covered in other reviews11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 21Cheung N. Mitchell P. Wong T.Y. Diabetic retinopathy.Lancet. 2010; 376: 124-136Abstract Full Text Full Text PDF PubMed Scopus (1912) Google Scholar, 39Mitchell P. Wong T.Y. Diabetic Macular Edema Treatment Guideline Working GroupManagement paradigms for diabetic macular edema.Am J Ophthalmol. 2014; 157: 505-513.e501–e508Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 48Martinez-Zapata M.J. Marti-Carvajal A.J. Sola I. et al.Anti-vascular endothelial growth factor for proliferative diabetic retinopathy.Cochrane Database Syst Rev. 2014; CD008721PubMed Google Scholar, 49Mohamed Q.A. Fletcher E.C. Buckle M. Diabetic retinopathy: intravitreal vascular endothelial growth factor inhibitors for diabetic macular oedema.BMJ Clin Evid. 2016;Mar 16; (pii: 0702; PubMed PMID: 27031563; PubMed Central PMCID: PMC4817243)PubMed Google Scholar and on the ICO website50International Council of OphthalmologyICO diabetic eye care.http://www.icoph.org/enhancing_eyecare/diabetic_eyecare.htmlGoogle Scholar and is not addressed here. In 2013, the ICO appointed the Diabetic Eye Care Task Force of 12 ophthalmologists from 11 different countries (see Appendix for list of members), who met over the course of 18 months for an in-depth review of the literature and the writing of the guidelines. The ICO invited national bodies (e.g., the American Academy of Ophthalmology) and international agencies (e.g., the International Diabetes Federation) to nominate members to be on the task force, with a view to having broad representations from different geographic regions and countries with varying resource levels, as well as a diverse mix of expertise ranging from retinal specialists to public health researchers. These guidelines were published in 2014. For the 2017 guidelines, a new task force was established (see Appendix for list of members) to review the 2014 guidelines and make recommendation for new evidence since the last guidelines were published. Specific sections on epidemiology of DR, classification of DR and DME, screening guidelines, referral guidelines, detailed ophthalmic assessment of DR, treatment of DR, treatment of DME, indications for vitrectomy, list of suggested indicators for evaluation of DR programs, and equipment were assigned to the specific members of the committee. A new section on management of DR in special circumstances that describes the management of DR and DME in patients with cataracts or who are pregnant also was incorporated in the 2017 edition. The members communicated via e-mail and teleconferences and met at major scientific conferences; first at Asia-Pacific Academy of Ophthalmology (APA02016), followed by Association for Research in Vision and Ophthalmology (ARV02016). Experts from the World Health Organization33World Health OrganizationWHO model list of essential medicines.http://www.who.int/medicines/publications/essentialmedicines/EML_2015_FINAL_amended_NOV2015.pdf?ua=1Google Scholar and the International Agency for the Prevention of Blindness and other national and international committees were invited to meetings to discuss recommendations. Revised drafts were reviewed for comments and the committee reached a unanimous concurrence before finalizing the guidelines for official launch at the International Agency for the Prevention of Blindness General Assembly Meeting in Durban, South Africa, in November 2016. Recommendations were made for DR and DME in terms of screening, referral, follow-up schedules, and types of treatment for high-resource and low- or intermediate-resource settings, broadly classified on country income level as defined by the World Bank and World Health Organization51World Health OrganizationHealth statistics and information systems.http://www.who.int/healthinfo/global_burden_disease/definition_regions/en/Google Scholar as follows: (1) high-resource settings, advanced or state-of-the-art screening and management of DR based on current evidence and clinical trials; (2) low- or intermediate-resource settings, essential or core to midlevel service for screening and managing DR with consideration for availability and access to care in different settings. Diabetic retinopathy is the most common specific microvascular complication of DM.11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Diabetic retinopathy develops over time in a person with DM, progressing from milder stages of nonproliferative DR (NPDR) to more advanced vision-threatening levels of DR that include PDR and DME. The pathogenesis of DR involves interrelated pathways related to hyperglycemia, including genetic and epigenetic factors, free radicals and advanced glycosylation end products, inflammatory factors, and VEGF. In many countries, DR is the most frequent cause of preventable blindness in working-age adults. A meta-analysis reported that 1 in 3 such persons (34.6%) had DR in the United States, Australia, Europe, and Asia and 1 in 10 such persons (10.2%) had vision-threatening DR (i.e., PDR, DME, or both); thus, based on the 2010 world DM population, more than 92 million adults have DR, 17 million have PDR, and 20 million have DME.14Yau J.W. Rogers S.L. Kawasaki R. et al.Global prevalence and major risk factors of diabetic retinopathy.Diabetes Care. 2012; 35: 556-564Crossref PubMed Scopus (2746) Google Scholar The Global Burden of Disease Study showed in that in 2010, there were 0.8 million blind persons and 3.7 million persons who had visual impairment because of DR.6Leasher J.L. Bourne R.R. Flaxman S.R. et al.Global estimates on the number of people blind or visually impaired by diabetic retinopathy: a meta-analysis from 1990 to 2010.Diabetes Care. 2016; 39: 1643-1649Crossref PubMed Scopus (327) Google Scholar Diabetic retinopathy develops with longer duration of DM and is associated with poor control of blood sugar, blood pressure, and blood lipids.11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 22Antonetti D.A. Klein R. Gardner T.W. Diabetic retinopathy.N Engl J Med. 2012; 366: 1227-1239Crossref PubMed Scopus (1156) Google Scholar Tight glycemic control has been shown in major trials to reduce the incidence and progression of DR.26The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group.N Engl J Med. 1993; 329: 977-986Crossref PubMed Scopus (22708) Google Scholar, 27Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group.Lancet. 1998; 352: 837-853Abstract Full Text Full Text PDF PubMed Scopus (18950) Google Scholar To a lesser extent, tight blood pressure control, particularly in diabetic persons with hypertension, also has been shown to reduce DR risk and progression and, importantly, cardiovascular complications.11Tan G.S. Cheung N. Simo R. et al.Diabetic macular oedema.Lancet Diabetes Endocrinol. 2017; 5: 143-155Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 21Cheung N. Mitchell P. Wong T.Y. Diabetic retinopathy.Lancet. 2010; 376: 124-136Abstract Full Text Full Text PDF PubMed Scopus (1912) Google Scholar However, good glycemic and blood pressure controls by themselves may not necessarily reduce the lifetime risk of DR developing to negligible levels, so persons with DM remain at risk of DR over time. The overall prevalence of DR in a community is influenced by the number of people with DM.52Sabanayagam C. Yip W. Ting D.S. et al.Ten emerging trends in the epidemiology of diabetic retinopathy.Ophthal Epidemiol. 2016; 23: 209-222Crossref PubMed Scopus (78) Google Scholar In high-resource settings with good health care systems, more people with early DM will have been diagnosed through screening. The prevalence of DR in people with newly diagnosed DM will be low, resulting in a lower overall prevalence of DR. In low- or intermediate-resource settings with less advanced health care systems, fewer people with early DM will have been diagnosed. Because the early stage of DR is asymptomatic, many people may be diagnosed with DM only when symptoms or complications have occurred. Thus, the prevalence of DR among people with newly diagnosed DM will be high, resulting in a somewhat higher overall prevalence of DR. The classic retinal lesions of DR are well described and include microaneurysms, intraretinal hemorrhages, venous beading (venous caliber changes consisting of alternating areas of venous dilation and constriction), intraretinal microvascular abnormalities, hard exudates (lipid deposits), and retinal neovascularization (Figs 1 and 2). These findings can be used to classify eyes as having the following overlapping spectrum of DR.Figure 2Fundus photographs and fluorescein angiogram showing features of severe stages of proliferative diabetic retinopathy and diabetic macular edema. A, Fundus photograph showing proliferative diabetic retinopathy with venous beading, new vessels elsewhere, and severe diabetic macular edema. B, Fundus photograph showing high-risk proliferative diabetic retinopathy with new vessels at the disc. C, Fundus photograph showing high-risk proliferative diabetic retinopathy with preretinal hemorrhage and new vessels on the disc. D, Fundus photograph showing high-risk proliferative diabetic retinopathy with new panretinal photocoagulation (PRP) scars. E, Fundus photograph showing proliferative diabetic retinopathy. New vessels appear on the disc and elsewhere. F, Fluorescein angiogram showing proliferative diabetic retinopathy. New vessels appear on the disc and elsewhere.View
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