Diabetic retinopathy, the most prevalent microvascular complication of both type 1 and type 2 diabetes, stands as a primary contributor to new cases of vision impairment among individuals aged 20 to 74 in the United States. This condition serves as the ocular manifestation of end-organ damage in diabetes mellitus. Factors that heighten the risk of diabetic retinopathy, or are closely linked to it, include diabetes duration, chronic hyperglycemia, nephropathy, hypertension, and dyslipidemia. Extensive diabetes management, aimed at achieving near-normoglycemia, has been proven in large-scale prospective randomized studies to prevent and/or delay the onset and progression of diabetic retinopathy, diminish the necessity for future ocular surgical interventions, and potentially enhance self-reported visual function.
This article, “Guidelines Side-By-Side,” offers a comprehensive comparison of the current clinical practice guidelines established by the American Academy of Ophthalmology (AAO), the American Optometric Association (AOA), and the American Diabetes Association (ADA). Through an examination of these recommendations, the objective of this article is to provide healthcare professionals with valuable insights and best practices for assessing diabetic retinopathy. This evidence-based approach is designed to improve health outcomes for individuals impacted by this condition.
Titles of Comparison:
| Titles | Diabetic Retinopathy Preferred Practice Pattern® | Eye Care of the Patient with Diabetes Mellitus | Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes |
|---|---|---|---|
| Society | American Academy of Ophthalmology (AAO) | American Optometric Association (AOA) | American Diabetes Association (ADA) |
| Publication Date | January 1, 2020 | May 18, 2023 | January 1, 2024 |
| Objective | Identify patients at risk of developing diabetic retinopathy – Encourage a collaborative approach between the patient, the primary care physician, and subspecialists in the management of the patient’s systemic disorder, with specific attention to control of blood sugar (hemoglobin A1c [HbA1c]), blood pressure, serum lipids, body weight, and the management of renal disease, coronary artery disease, and neuropathy – Encourage and provide lifelong monitoring of retinopathy progression – Treat patients with visual loss or those at risk for visual loss from diabetic retinopathy – Minimize the side effects of treatment that might adversely affect the patient’s vision and/or vision related quality of life. | The objectives of this Guideline are to assist doctors of optometry in achieving the following: – Identification of individuals at risk for diabetes – Identification of individuals with undiagnosed diabetes – Identification of individuals at risk of vision loss from diabetes – Identification of individuals in need of lifestyle management to reduce complications of diabetes – Preservation of vision by reducing the risk of vision loss in persons with diabetes through timely diagnosis, intervention, determination of need for future evaluation, and appropriate referral – Improvement in the quality of care rendered to persons with diabetes – Education of individuals and health care practitioners regarding the ocular complications of diabetes – Dissemination of information and education of individuals on the benefits of vision rehabilitation – Provision or referral for vision rehabilitation services for persons with vision loss from diabetes. | The American Diabetes Association (ADA) “Standards of Care in Diabetes,” referred to here as the Standards of Care, is intended to provide clinicians, researchers, policy makers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. |
| Target Population | The patient population includes all patients with diabetes mellitus. | The patient population includes all patients with diabetes mellitus. | The target audience for the Standards of Care includes primary care physicians, endocrinologists, nurse practitioners, physician associates/assistants, pharmacists, dietitians, diabetes care and education specialists, and all members of the diabetes care team. |
| Methodology | Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1 (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2 (GRADE) group are used. | Based on the IOM/NASEM reports, the American Optometric Association (AOA) Evidence-Based Optometry (EBO)Committee developed a 14-step process to meet the new evidence-based recommendations for trustworthy guidelines | The Standards of Care includes discussion of evidence and clinical practice recommendations intended to optimize care for people with diabetes by assisting health care professionals and individuals in making shared decisions about diabetes care. The recommendations are informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options. |
| Graded Strength of Recommendations | Yes | Yes | Yes |
| Graded Level of Evidence | Yes | Yes | Yes |
| Systematic Review Conducted | Yes | Yes | Yes |
| Literature Review Conducted | Yes | Yes | Yes |
| COIs & Funding Source(s) Disclosed | Yes | Yes | Yes |
| Full-text | Diabetic Retinopathy Preferred Practice Pattern® | American Optometric Association – Evidence-based Clinical Practice Guideline Eye Care of the Patient with Diabetes Mellitus Second Edition | Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes—2024 |
| Summary | Diabetic Retinopathy | Eye Care Of The Patient With Diabetes Mellitus | Standards of Care in Diabetes—2024 |
Assessment Overview
| Titles | Diabetic Retinopathy Preferred Practice Pattern® | Eye Care of the Patient with Diabetes Mellitus | Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes |
|---|---|---|---|
| Screening for Retinopathy | Initial screening recommended at diagnosis for Type 2 diabetes and 5 years after diagnosis for Type 1.Frequency depends on retinopathy severity. | Annual dilated eye exams for all diabetic patients, regardless of age soon after diagnosis | Screen annually for diabetic retinopathy (DR) starting at diagnosis for Type 2 diabetes.For Type 1, start screening within 5 years of diagnosis. |
| Screening Methods | Preferable to perform a dilated fundus examination, or use imaging such as fundus photography. | Comprehensive eye exam with dilated pupil evaluation. | Fundus photography or dilated eye exam by an ophthalmologist or optometrist. |
| Management of Non-Proliferative Diabetic Retinopathy (NPDR) | Focus on monitoring progression; if significant, refer to ophthalmology for further evaluation. | Blood sugar control, blood pressure management, and lipid management are key. | Control blood glucose, blood pressure, and lipids to prevent progression. |
| Management of Proliferative Diabetic Retinopathy (PDR) | Treatment options include panretinal laser photocoagulation (PRP), anti-VEGF injections, or vitrectomy if necessary. | Referral for possible laser photocoagulation or anti-VEGF therapy if PDR is present. | Refer to retinal specialist for possible laser therapy or anti-VEGF injections if needed. |
| Management of Diabetic Macular Edema (DME) | Anti-VEGF therapy is considered first-line, with laser photocoagulation and corticosteroids as alternatives. | In cases of DME, anti-VEGF injections, corticosteroid injections, or laser therapy may be indicated. | Anti-VEGF injections (e.g., ranibizumab, aflibercept), or corticosteroid injections, and laser therapy may be used. |
| Blood Pressure Control | Tight blood pressure control (typically <140/90 mm Hg) is recommended to reduce risk of progression. | Blood pressure control is important in preventing or slowing DR progression. | Target <140/90 mm Hg for most patients; lower targets for some groups may be considered. |
| Blood Glucose Control | Tight glycemic control is emphasized to reduce onset and progression of DR. | Strict blood glucose control is emphasized to reduce risk of DR progression. | Achieving HbA1c target <7% (individualized) to reduce risk of retinopathy development and progression. |
| Lipid Control | Lipid management to target recommended levels, particularly LDL <100 mg/dL, for diabetic retinopathy patients. | Lipid control is part of comprehensive diabetes care. | Statins should be used as appropriate to achieve LDL levels <100 mg/dL (or <70 mg/dL for high-risk patients). |
| Referral Criteria | Early referral to a retinal specialist if progression to severe NPDR, PDR, or DME occurs. | Referral to a retina specialist for advanced DR or DME is strongly recommended. | Refer to an ophthalmologist if any signs of retinopathy are present, especially with worsening DR. |
| Follow-up and Monitoring | Follow-up every 6-12 months for patients with mild NPDR, and more frequently for severe disease. | Regular follow-up depending on the severity of retinopathy. | Frequency of follow-up varies based on severity of retinopathy. Generally, annual exams, or more frequent for advanced disease. |
| Pregnancy Considerations | More frequent screenings during pregnancy due to potential rapid progression of retinopathy. | Continue regular exams during pregnancy, with increased monitoring if retinopathy is present. | Annual eye exams should continue during pregnancy if DR is present. |
| Role of Anti-VEGF Therapy | Anti-VEGF therapy is a first-line treatment for DME and PDR. | Anti-VEGF injections are standard care for DME and PDR. | Strongly recommended for treating DME and PDR. |
Key Takeaways:
- Screening:
- All three guidelines emphasize the importance of annual screening for diabetic retinopathy (DR) with dilated eye exams, starting from the time of diagnosis or a few years after diagnosis, depending on the type of diabetes.
- Management:
- Blood glucose control is a cornerstone in all guidelines to prevent or slow the progression of retinopathy.
- Blood pressure and lipid management are also critical factors, with recommendations aligning on keeping targets within specific ranges to prevent DR progression.
- Treatment of DR:
- Non-proliferative DR: All guidelines emphasize regular monitoring and tight metabolic control.
- Proliferative DR: Referral for laser therapy or anti-VEGF injections is recommended in all guidelines.
- Diabetic Macular Edema: Anti-VEGF therapy is universally recognized as a first-line treatment for DME, with other options like corticosteroid injections or laser photocoagulation considered based on the situation.
- Referral to specialists:
- Each guideline stresses the importance of referral to retinal specialists for patients with more advanced stages of retinopathy (proliferative DR, severe NPDR, DME).
- Patient-Centered Care:
- Both emphasize individualized treatment based on patient history and response to previous therapies.
Key Differences:
- Focus Areas:
- Standards of Care in Diabetes is broad and addresses the overall management of diabetic complications, including retinopathy, neuropathy, and foot care.
- Eye Care of the Patient with Diabetes Mellitus focuses specifically on eye care, providing detailed recommendations for managing diabetic retinopathy and other eye-related complications of diabetes.
- Diabetic Retinopathy Preferred Practice Pattern® is highly specific to the diagnosis and management of diabetic retinopathy, detailing advanced treatment options like laser therapy and anti-VEGF injections.
- Screening Guidelines:
- Screening for retinopathy is a shared goal in all documents, but the Standards of Care also includes a broader recommendation for comprehensive diabetes management, whereas the Diabetic Retinopathy Preferred Practice Pattern® and Eye Care of the Patient with Diabetes Mellitus are more focused on the methods and best practices for eye-specific screenings and interventions.
In summary, while each guideline presents slightly different emphases, they are all aligned in recognizing the need for comprehensive management that includes glycemic control, blood pressure management, screening, and specialist referral. The use of anti-VEGF therapy in advanced stages of retinopathy is a key treatment modality across all three guidelines.
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