1. Canadian Diabetes Association Clinical Practice Guidelines Retinopathy Chapter 30 Shelley R. Boyd, Andrew Advani, Filiberto Altomare, Frank Stockl

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Retinopathy Checklist SCREEN regularly DELAY onset and progression with glycemic and blood pressure control ± fibrate TREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreoretinal surgery 2013

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CategoryProliferative Retinopathy Macular Edema Type 1 DM23%11% Type 2 DM on insulin14%15% Type 2 DM on oral agents 3%4% Klein R, et al. Diabetes care 1992;15(12):1875-91 Klein R, et al. Ophthalmology 1984;91(12):1464-74 Diabetic Retinopathy Most Common Cause of Blindness Among Working Age

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Visual loss is associated with: – Increased falls – More hip fractures – A four-fold increase in mortality – Early death (in T1DM) Retinopathy Increases Morbidity and Mortality

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1. Macular Edema 2. Non-proliferative and Proliferative 3. Retinal Capillary Closure Types of Retinopathy

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diffuse or focal vascular leakage at the macula Macular Edema

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Blood vessel changes Non-proliferative – Microaneurysms, intraretinal hemorrhage, vascular tortuosity and vascular malformation Proliferative – Abnormal vessel growth Non-proliferative/Proliferative Retinopathy

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Seen with fluorescein angiography Potentially blinding complication Currently no treatment options Retinal Capillary Closure

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Retinopathy is rare in prepubertal children Screen annually in T1DM, 5 years after onset in individuals ≥15 years of age Screening Reduces Risk of Blindness (T1DM)

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Retinopathy may be present in 21-39% of patients with T2DM at diagnosis Screen every 1-2 years in T2DM beginning at diagnosis Screening Reduces Risk of Blindness (T2DM)

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Longer duration of diabetes Elevated A1C Hypertension Dyslipidemia Low hemoglobin level Pregnancy (with T1DM) Proteinuria Severe retinopathy itself Risk Factors for Progression

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1. Glycemic control: target A1C ≤7% 2. Blood pressure control: target BP <130/80 3. Lipid-lowering therapy: fibrates have been shown to decrease progression and may be considered 2013 Delay of the Disease

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-986. Primary PreventionSecondary Intervention 76% RRR 54% RRR Reduction in Retinopathy with Intensive Glycemic Control

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Reduction in Microvascular Complications with Blood Pressure Control: UKPDS 38 UKPDS. BMJ 1998;317:703-713 guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association UKPDS. BMJ 1998;317:703-713 Reduction in Retinopathy with Blood Pressure Control: UKPDS 38

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Intensive glycemic control and combination of fenofibrate and simvastatin, but not intensive blood pressure control, reduced the rate of progression of diabetic retinopathy in this older, high-risk population. EffectOdds Ratio95% CIP-value Glycemia0.67(0.51 - 0.87)0.0025 Lipid0.60(0.42 - 0.86)0.0056 BP1.23(0.84 - 1.79)0.29 ACCORD Study Group. N Engl J Med 2010; 363(3):233-244. ACCORD Eye: Results

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association FIELD: Retinopathy Requiring Laser FIELD Study Investigators. Lancet 2005 ; 366 (9500): 1849-61 Cumulative risk (%) Years from randomization HR = 0.70 95% CI = 0.58–0.85 p = 0.0003 10 8 6 4 2 0 012345 Placebo 6 Fenofibrate

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetic Retinopathy CAN be Treated 1.Pan-retinal photocoagulation  laser therapy – Reduces blindness by 90% in severe non-proliferative or proliferative retinopathy 2. Local (intra-ocular) pharmacologic intervention  VEGF antagonists – Ranibizumab and bevacizumab improve vision 3. Surgical intervention  vitrectomy

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Sight-threatening Retinopathy MUST be Prevented with good blood sugar and blood pressure control (± fenofibrate); Detected through screening; and Treated with laser therapy, anti-VEGF medications or vitrectomy to save VISION

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1.In individuals ≥15 years of age with type 1 diabetes, screening and evaluation for retinopathy by an expert professional should be performed annually starting 5 years after the onset of diabetes [Grade A, Level 1]. Recommendation 1

21. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2.In individuals with type 2 diabetes, screening and evaluation for diabetic retinopathy by an expert professional should be performed at the time of diagnosis of diabetes [Grade A, Level 1] and annually thereafter. The interval for follow-up assessments should be tailored to the severity of the retinopathy. In those with no or minimal retinopathy, the recommended interval is 1 to 2 years [Grade A, Level 1].

22. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 3 3.Screening for diabetic retinopathy should be performed by experienced professionals, either in person or through interpretation of retinal photographs taken through dilated pupils [Grade A, Level 1].

23. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 4 4. To prevent the onset and delay the progression of diabetic retinopathy, people with diabetes should be treated to achieve optimal control of blood glucose [Grade A, Level 1A] and blood pressure [Grade A, Level 1A].

24. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 5 5.Though not recommended for CVD prevention or treatment, fenofibrate in addition to statin therapy, may be used in patients with type 2 diabetes to slow the progression of established retinopathy [Grade A, Level 1A]. 2013

25. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 6 6.Patients with sight-threatening diabetic retinopathy should be assessed by a general ophthalmologist or retina specialist [Grade D, Consensus]. Laser therapy and/or vitrectomy [Grade A, Level 1A] and/or pharmacologic intervention [Grade A, Level 1A] should be used.

26. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 7 7.Visually disabled people should be referred for low-vision evaluation and rehabilitation [Grade D, Consensus].

27. CDA Clinical Practice Guidelines www.guidelines.diabetes.cawww.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca www.diabetes.ca – for patients