ICO International Clinical Guidelines:

Diabetic Retinopathy (Management Recommendations)

(Download this Guideline as a PDF file - 95 KB)

Management Recommendations for Patients with Diabetes

Severity of Retinopathy	Presence of CSME*	Follow-up (Months)	Scatter (Panretinal) Laser	Fluorescein Angiography	Focal Laser†
1. Normal or minimal NPDR	No	12	No	No	No
2. Mild to moderate NPDR	No	6-12	No	No	No
3. Severe or very severe NPDR	Yes	2-4	No	Usually	Usually*^
4. Severe or very severe NPDR	No	2-4	Sometimes‡	Rarely	No
5. Non-high-risk PDR	Yes	2-4	Sometimes‡	Usually	Usually**
6. Non-high-risk PDR	No	2-4	Sometimes‡	Rarely	No
7. High-risk PDR	Yes	2-4	Sometimes‡	Usually	Usually^
8. High-risk PDR	No	3-4	Usually‡	Rarely	No
9. High-risk PDR not amenable to photocoagulation (e.g., media opacities)	Yes	3-4	Usually‡	Usually	Usually**
10. High-risk PDR not amenable to photocoagulation (e.g., media opacities)	_	1-6	Not Possible††	Occasionally	Not Possible††

* Exceptions include: hypertension or fluid retention associated with heart failure, renal failure, pregnancy, or any other causes that may aggravate macular edema. Deferral of photocoagulation for a brief period of medical treatment may be considered in these cases. Also, deferral of CSME treatment is an option when the center of the macula is not involved, visual acuity is excellent, and the patient understands the risks.

† Focal photocoagulation refers to direct focal laser to microaneurysms or a grid photocoagulation pattern to areas of diffuse leakage or nonperfusion seen on fluorescein angiography.

^ Deferring focal photocoagulation for CSME is an option when the center of the macula is not involved, visual acuity is excellent, close follow-up is possible, and the patient understands the risks. However, initiation of treatment with focal photocoagulation should also be considered because although treatment with focal photocoagulation is less likely to improve the vision, it is more likely to stabilize the current visual acuity.

‡ Scatter (panretinal) photocoagulation surgery may be considered as patients approach high-risk PDR. The benefit of early scatter photocoagulation at the severe nonproliferative or worse stage of retinopathy is greater in patients with Type 2 diabetes than in those with Type I. Treatment should be considered for patients with severe NPDR and Type 2 diabetes. Other factors, such as poor compliance with follow-up, impending cataract extraction or pregnancy, and status of fellow eye will help in determining the timing of the scatter photocoagulation.

** Some experts feel that it is preferable to perform the focal photocoagulation first, prior to scatter photocoagulation, to minimize scatter laser-induced exacerbation of the macular edema.

†† Vitrectomy indicated in selected cases.

CSME = clinically significant macular edema; NPDR = nonproliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy

* Adapted from the American Academy of Ophthalmology Summary Benchmarks, November 2006 (www.aao.org)

(Download this Guideline as a PDF file - 95 KB)

Next: Esotropia (Initial and follow-up evaluation)

Also see:

• International Clinical Guidelines (Preface)
  
  
• Introduction to the Guidelines
  
  
• List of Guidelines