How updated ICO guidelines impact patients' diabetic eye care

July 11, 2018

With the proliferation of diabetes around the globe, ophthalmologists located in countries that are treating diabetic retinopathy and diabetic macular edema (DME) more often now are in need of detailed guidelines to assist them.

This is what led a team of eye care providers to recently update the International Council of Ophthalmology's (ICO) Guidelines for Diabetic Eye Care.

The original guidelines were released in 2013. Yet in the couple of years since those guidelines were published, there have been changes that warranted an update, said Tien Yin Wong, MD, PhD, medical director, Singapore National Eye Centre, and academic chair, Ophthalmology and Visual Sciences Program, Duke-NUS Medical School, National University of Singapore, Singapore. Dr. Wong is chairman of the 2016 Diabetic Eye Care Committee that updated the guidelines.

"The ICO felt the need for a revised set of guidelines. First, there's the changing epidemiology of diabetes affecting many countries outside of the Western world, but there are no guidelines for many of these developing countries with lower resources than in the Western developed countries with more resources and more ophthalmologists," Dr. Wong said.

"Second, there is emerging eye technology, such as cost-effective screening digital retinal cameras," Dr. Wong said. "Third, there's the changing treatment for DME and proliferative diabetic retinopathy with the widespread use of anti-vascular endothelial growth factor [VEGF] therapy. How it should be used in different countries with different levels of resource settings is not clear."

That's where the guidelines come into the picture. The 40-page document (available at http://www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare.pdf) addresses screening, referral, follow-up, and treatment for diabetic retinopathy and DME.

However, it also stratifies its recommendations according to high-resource settings (such as the United States) and intermediate- and low-resource settings. The document includes pictures to show how various forms and signs of diabetic retinopathy and DME appear.

Guideline changes

Compared with its original publication, the guidelines provide some updates and new information.

"There is increased recognition of the value of routine, universal screening for diabetic retinopathy among all persons with diabetes," Dr. Wong said. "This has been clearly demonstrated in the UK. There is also increased use of new technology such as OCT for diagnosis and screening of diabetic retinopathy."

The mainstream use of anti-VEGF therapy even in many low-resource countries also led to some of the guideline revisions.

Another area addressed by the updated ICO guidelines is whether a pregnant woman with diabetic retinopathy should undergo a vaginal delivery, said retinal specialist Srilaxmi Bearelly, MD, MHS, assistant professor of ophthalmology, Columbia University Medical Center, New York.

"The ICO guidelines specifically state that the presence of diabetic retinopathy by itself, 'should not be considered a contraindication to vaginal birth,'" she said.

The updated guidelines also now address the presence of concurrent diabetic retinopathy and cataract surgery.

Specifically, they advise that a patient with a mild cataract but without vision loss and with a clear fundus view may not require cataract surgery. If there is a moderate cataract, physicians should carefully assess diabetic retinopathy status and attempt to treat any severe nonproliferative diabetic retinopathy with laser pan-retinal photocoagulation and/or DME with focal/grid laser or anti-VEGF therapy before cataract surgery.

"Once DR/DME is stable, consider cataract surgery to improve vision," the guidelines advise.

In a patient with diabetic retinopathy and severe to advanced cataract with a poor fundus view, consider early cataract surgery followed by assessment and treatment as necessary.

"If DME is present, consider anti-VEGF before surgery, at the time of surgery, or after surgery if DME is discovered when the media is cleared," the guidelines recommend.

 

A broader context

The updated information from the ICO can potentially help surgeons in all settings worldwide.

The guidelines "give countries who do not have the necessary history or tradition of treating diabetic retinopathy the foundation of what is the 'basic' care model of diabetes: screening, appropriate and timely referral, and what constitutes the basic examination, and what constitutes adequate treatment," Dr. Wong said. "Many countries cannot depend on large-scale randomized trials done in the U.S. or Europe to guide their care of diabetic patients."

However, ophthalmologists abroad are not the only ones who might refer to the guidelines, Dr. Bearelly said.

"While there are not new recommendations for U.S. retinal specialists, it should be recognized that there are many segments of our U.S. population that have poor health awareness and inadequate access to care, particularly in rural areas," Dr. Bearelly said. "Even though we are able to prevent 98% of blindness from diabetes with our current treatments, only about 50% of those with diabetes get screening. The ICO guidelines allow for telemedicine approaches to diabetic retinopathy screening."

Typically, retinal specialists in the United States use information from large randomized trials, such as those performed by DRCR.net-the Diabetic Retinopathy Clinical Research Network-to help guide care, Dr. Bearelly said.

However, the ICO guidelines take into account both randomized trials and experience from real-world experience in various settings, she explained.

One other area the guidelines can assist with is expanding the scope of care beyond just eye-care professionals.

"The diabetes epidemic is larger than the eye-care community is capable of addressing," Dr. Bearelly said. "Screening, referral, and follow-up guidelines such as these help to involve physicians and other health-care providers with evidence-based management principles."

Disclosures:

Dr. Wong and Dr. Bearelly have no related disclosures.