Epidemiology
Diabetic retinopathy is a common microvascular complication of diabetes mellitus.
People with Type 1 Diabetes
People with Type 1 Diabetes
-
Retinopathy is rare in children before puberty.
-
The prevalence of diabetic retinopathy disease is 24–27% in people with type 1 diabetes.
-
Clinically significant macular edema can occur in up to 10% of people with type 1
diabetes.
People with Type 2 Diabetes
People with Type 2 Diabetes
-
At the time of diagnosis, 2–16% of patients already have retinopathy.
-
Retinopathy can be detected in 9–16% of patients.
-
Diabetic maculopathy can occur in 6% of patients.
Symptoms
Diabetic retinopathy and maculopathy have long been asymptomatic. Therefore, regular
ophthalmological control intervals must be observed even without deterioration of
vision.
Warning signs that indicate retinal complications include:
If the macula is affected:
-
Reading difficulties up to the loss of the ability to read,
-
Color sense disorders,
-
General visual deterioration in the sense of blurred vision,
-
“Floaters” in front of the eye caused by vitreous hemorrhages up to practical blindness
due to persistent vitreous hemorrhages or in case of tractive retinal detachments.
Particularity
Euglycemic reentry (early worsening) of retinopathy affects patients with type 1 and
type 2 diabetes. It is rare (< 5 % of patients), occurs mainly within the first 12
months of metabolic improvement, is more frequent in patients with long-term diabetes
(> 10 years) and long-term poorly-controlled blood glucose (HbA1c>10 %). However,
the most important factor is a pre-existing retinopathy, regardless of its degree.
It is not prevented by a gradual improvement of HbA1c. In the long run, the positive
effect of blood glucose improvement prevails in patients with type 1 diabetes.
Table 1 Stage classification, ophthalmological findings and therapy for retinopathy and maculopathy.
Stage
|
Ophthalmological findings
|
Ophthalmological therapy
|
1.1 Non-proliferative diabetic retinopathy
|
Mild
|
Microaneurysms
|
No photocoagulation
|
Moderate
|
Additionally, individual intraretinal bleeding, venous beading (venous caliber fluctuations)
|
No photocoagulation
|
Severe
|
“4-2-1 rule”>20 individual microaneurysms, intraretinal bleeding in 4 quadrants or
venous beading in 2 quadrants or intraretinal microvascular anomalies (IRMA) in1 quadrant
|
Photocoagulation only for risk patients
|
1.2 Proliferative diabetic retinopathy
|
|
Proliferation of papilledema, proliferation not close to the papilla
|
Photocoagulation, only in selected cases intravitreal surgical drug administration
(IVOM)
|
|
Vitreous hemorrhage retinal detachment
|
Photocoagulation, if possible; otherwise possibly vitrectomy
|
2. Diabetic maculopathy
|
2.1 Diabetic macular edema
|
Spot/fleck-like zone(s) of edema, intraretinal bleeding or hard exudates at the posterior
pole
|
No photocoagulation
|
|
Visually threatening if close to macula=clinically significant
|
|
|
▪ Fovea not included
|
Targeted photocoagulation
|
|
▪ Fovea included
|
Intravitreal surgical drug delivery, optionally targeted laser coagulation
|
2.2 Ischemic maculopathy
|
Diagnosis by fluorescein angiography: occlusion of the perifoveal capillary network
|
No therapy possible
|
Diagnostics
The following must be examined:
-
Visual acuity,
-
Anterior segment of the eye,
-
Ocular fundus with binocular-biomicroscopic fundoscopy (with dilated pupil),
-
Eye pressure in severe non-proliferative or proliferative retinopathy, in neovascularization
of the iris,
-
Optical coherence tomography (OCT) optional for the differential diagnosis of maculopathy,
or obligatory in case of diabetic maculopathy requiring therapy,
-
Fluorescein angiography in certain constellations of advanced diabetic retinopathy
or maculopathy.
The findings are sent to the family doctor/diabetologist on the documentation form
“Ophthalmologic notification” (see [Fig. 1]).
-
▶ [Fig. 1]: Documentation form for the general practitioner/diabetological to communicate with
the ophthalmologist
-
▶ [Fig. 2]: Documentation form for the ophthalmologic to communicate with the general practitioner
/diabetologist. Download at:www.leitlinien.de/nvl/diabetes/netzhautkomplikationen
-
▶ [Fig. 3]: Procedure for diabetes according to the National Health Care Guidelines for Diabetic
Retinopathy and Maculopathy.
-
▶ Diabetes health passport: https://eref.thieme.de/ZBNKV (only available in german)
Fig. 1 Documentation form for the general practitioner/diabetological communication to the
ophthalmologist (Dokumentationsbogen für die hausärztliche/diabetologische Mitteilung
an den Augenarzt). Source: German Medical Association (Bundesärztekammer - BÄK), National
Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung
- KBV), Association of Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen
Medizinischen Fachgesellschaften - AWMF). National Healthcare Guideline Prevention
and Treatment of Retinal Complications in Diabetes Long Form (Nationale Versorgungs-
Leitlinie Prävention und Therapie von Netzhautkomplikationen bei Diabetes-Langfassung),
2nd Edition. Version 2. 2015. www.netzhautkomplikationen. versorgungsleitlinien.de;
DOI: 10.6101/AZQ/000318. [rerif]
Treatment Objectives
Avoiding visual loss and blindness through interdisciplinary cooperation with:
-
Near-normal blood glucose control (see DDG Guidelines “Therapy of Type 1 Diabetes”
and “Medical antihyperglycaemic treatment of diabetes mellitus type 2 “),
-
Blood pressure normalization (see DDG Guideline “Management of hypertension in patients
with diabetes mellitus”) and
-
Ophthalmological therapy.
▶ [Tab. 1]: Stage classification, ophthalmological findings and therapy
Times of Examination
Fundamental
-
If no retinopathy or general risk factors are present, examination by the ophthalmologist
every 2 years. The general risk factors should have been communicated to the ophthalmologist
in advance on the documentation form “General practitioner/diabetological communication
to the ophthalmologist” ( [Fig. 1]).
-
If there is no retinopathy and one or more general risk factors are present or the
ophthalmologist is not aware of the general risk factors: examination by the ophthalmologist
once a year.
-
If retinopathy is already present: control intervals according to the ophthalmologist's
instructions.
Exceptions to the Rule
-
Children below the age of 11 must be examined only if the diabetes has been present
for 5 years.
-
Pregnant women: immediately upon detection of pregnancy, then every 3 months. If a
retinopathy develops or progresses during pregnancy, the ophthalmologist determines
the intervals.
-
Patients with type 2 diabetes: immediately upon detection of the disease.
-
Before planned and after rapid and significant blood glucose reduction, all patients
must be monitored by an ophthalmologist at short notice (risk of temporary worsening
of retinopathy), especially if retinopathy is known to be present.
-
Intensification of therapy with insulin (continuous subcutaneous insulin infusion
[CSII], intensified conventional therapy [ICT]) and with glucagon-like peptide-1 (GLP-1)-receptor
agonists should be accompanied by careful medical attention to monitor retinopathy
worsening.
Addresses on the Internet
Addresses on the Internet
-
Website of the German Diabetes Society (Deutsche Diabetes Gesellschaft): www.deutsche-diabetes-gesellschaft.de
-
Website of the Initiative Group Early Diagnosis of Diabetic Eye Diseases (IFDA) and
the Working Group Diabetes and Eye (AGDA) (Initiativgruppe Früherkennung diabetischer
Augenerkrankungen (IFDA) und der Arbeitsgemeinschaft Diabetes und Auge (AGDA)):
www.diabetes-auge.de
-
Information on the topic of diabetic eye diseases by the Professional Association
of Ophthalmologists in Germany: http://cms.augeninfo.de/fileadmin/pat_brosch/diabetes.pdf
-
Information from the Medical Center for Quality in Medicine (ÄZQ) (Ärztlichen Zentrums
für Qualität in der Medizin (ÄZQ)); Berlin: National Healthcare Guideline (Nationale
Versorgungsleitlinie). Prevention and therapy of retinal complications in diabetes
(Prävention und Therapie von Netzhautkomplikationen bei Diabetes).([Fig. 2]
[3])
Long version 2nd edition 2015 at:
www.versorgungsleitlinien.de
Fig. 2 Documentation form for the ophthalmologic communication to the general practitioner/diabetologist
(Dokumentationsbogen für die augenfachärztliche Mitteilung an den Hausarzt/Diabetologen).
Source: German Medical Association (Bundesärztekammer - BÄK), National Association
of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung - KBV),
Association of Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen
Medizinischen Fachgesellschaften - AWMF). National Healthcare Guideline Prevention
and Treatment of Retinal Complications in Diabetes Long Form (Nationale Versorgungs-
Leitlinie Prävention und Therapie von Netzhautkomplikationen bei Diabetes-Langfassung),
2nd Edition. Version 2. 2015. www.netzhautkomplikationen. versorgungsleitlinien.de;
DOI: 10.6101/AZQ/000318. [rerif]
Fig. 3 Procedure for type 2 diabetes according to the National Healthcare Guidelines for
Diabetic Retinopathy and Maculopathy [3]. [rerif]
German Diabetes Association: Clinical Practice Guidelines
This is a translation of the DDG clinical practice guideline
published in Diabetologie 2020; 15: S175–S180,
DOI 10.1055/a-1194-1638