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Ask your retinal specialists when to refer diabetic retinopathy
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ATLANTA – Today’s technology allows optometrists to be proactive when managing and referring patients with diabetic retinopathy, Jay M. Haynie, OD, said in a presentation here at SECO.
His 2-hour talk on modern-day diabetes was sponsored by Primary Care Optometry News.
Proper classification can help the optometrist decide when to refer. Patients should be evaluated for hemorrhage or microaneurysm (H/MA), venous beading (VB), intraretinal microvascular abnormalities (IRMA) and neovascularization (NEO), he said, and he offered a clinical pearl.
“If you see a squirrely blood vessel in the retina and you trace it back to a vein, you have IRMA,” Haynie said. “But if you trace it back to an artery, it’s highly probable that’s retinal neovascularization.”
The presence of at least one microaneurysm is considered mild nonproliferative diabetic retinopathy (NPDR), he said. The presence of H/MA greater than that shown in the Early Treatment Diabetic Retinopathy Study (ETDRS) Research Group standard photograph No. 2A and/or cotton-wool spots, VB or IRMA is classified as moderate NPDR.
If the H/MA is greater than standard photograph No. 2A in four quadrants, or VB is present in two or more quadrants, or IRMA is greater than that shown in the ETDRS standard photograph No. 8A in at least one quadrant, the patient has severe NPDR. This follows the “4-2-1 rule,” Haynie said.
Very severe NPDR is diagnosed if two or more criteria of severe NPDR are present. There is no frank neovascularization, he said.
Haynie shared his personal referral criteria.
“If you have a patient with mild NPDR, they come back every year,” he said. “For moderate, it’s 6 to 12 months. Severe is 4 to 6 months. Very severe is every 3 months.
“However, I am starting to send severe and very severe to retina,” Haynie continued. “Lucentis [ranibizumab, Genentech] may actually prevent proliferative disease. If you have a patient with ischemic disease and they’re headed to proliferative disease, we once would wait until something bad happened. That’s reactive optometry. We’re in a situation with technology where we can become very proactive.”
Haynie recommended asking your retinal specialists when they are intervening.
“It will help you understand when patients need to be referred,” he said. “Consider the patient’s control. Consider the success of therapy. Center-involved diabetic macular edema should be referred and treated. Consider risk of progression. Fifty-one percent of severe NPDR go on to proliferative. Think of their risk profile and think about your own comfort level. Never lose sleep over a patient. If you’re that nervous, send it to someone else.”
Proliferative disease requires prompt referral to a retinal specialist, Haynie said.
“If rubeosis is present, these patients get treated within 48 hours in-office,” he said.
Haynie said he documents any clinically significant macular edema (CSME) because it is risk indicator.
“If CSME is left untreated, they have risk for moderate vision loss,” he said. “Now it’s more about center-involved vs. non center-involved.”
He brings patients with macular edema back for 6-week follow-up; those with edema with no change come back in 3 months. – by Nancy Hemphill, ELS, FAAO
References:
Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991;98:786-806.
Haynie JM. Modern-day diabetes. Presented at: SECO; Feb. 28-March 4, 2017; Atlanta.
Disclosure: Haynie reported he is a consultant for Arctic Dx, Carl Zeiss Meditec and Topcon.