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Part 3, Chapter 9: Manual Exhibit 3-9-D

Diabetic Retinopathy Screening/Monitoring
  1. Background.  Diabetic Retinopathy is the leading cause of blindness among the American Indians/Alaska Natives.  Early detection and timely treatment of Diabetic Retinopathy can often delay or prevent severe vision loss.

    Advances in the management of Diabetes Mellitus has resulted in an increase in longevity and an associated increased duration of Diabetic Retinopathy.  The prevalence and severity of Diabetic Retinopathy is increasing since these are directly related to duration of disease.  The opportunities for intervention in Diabetic Retinopathy are more effective when the disorder is treated early.  Unfortunately, visual symptoms in Diabetic Retinopathy occur late.  For these reasons, an effective screening program for Diabetic Retinopathy is essential in any comprehensive eye care program.

    In order to provide the early detection so essential in the management of Diabetic Retinopathy and to monitor the progression of retinopathy to insure timely referral, an organized Diabetic Retinopathy screening and monitoring process is essential.  This process must include an effective recall and followup system.  The following protocol is recommended in establishing a screening, monitoring, recall, and referral system.

  2. Screenings Protocol for Eye Disease in Diabetes Mellitus.  All patients with diabetes mellitus should be screened for eye disease each year.  The examiner need not in all cases be an Optometrist or Ophthalmologist, but may be another appropriately trained provider.  For a screener outside the eye clinic, a fundus examination with dilation is sufficient.  Standardized fundus photographs or equivalent retinal imaging for evaluation by an appropriately trained reviewer may be substituted.  Visual acuity and intraocular pressure determinations are core features of any screening protocol and should be included in a Diabetic Retinopathy screening program.
  3. Minimum Eye Examination.  The suggested minimum exam in the eye clinic is:
    1. Visual acuity
    2. Biomicroscopy
    3. Tonometry
    4. Dilated fundus examination
  4. Recommended Disposition of Patients by Diagnostic Groups.  Each Indian Health Service facility's Resource and Patient Management System has patient recall capability and should be used to maximize compliance for timely diabetic eye exams.
    1. Category I.  No retinopathy or mild non-proliferative Diabetic Retinopathy: Followup in 1 year.
    2. Category II.  Moderate non-proliferative Diabetic Retinopathy: Followup 6 - 12 months.
    3. Category III.  Development beyond moderate non-proliferative Diabetic Retinopathy:  Referral for ophthalmologic care with management as indicated by preferred practice patterns.
    4. Category IV.  Refer for ophthalmologic care.  Early referral for surgical flexibility is encouraged.
      1. Proliferative disease of any type.
      2. Clinically-significant macular edema.
      3. Best corrected visual acuity worse than 20/40 without explanation.
      4. Vitreous Hemorrhage.