Lesson 5: Management guidelines

From the public health perspective, vision loss from diabetic retinopathy (DR) can be prevented broadly through three key activities:

1. Increasing public awareness and targeted education about the complications of diabetes in the eye.
2. Implementing community or national level screening for early detection of DR.
3. Providing timely referral pathways and appropriate treatment for people with diabetes who develop DR.

High-income countries which have the necessary health care structures and
resources (funding, trained workforce, medical and surgical facilities) must consider implementing early detection systems and care pathways. Intermediate and low resourced settings face a substantial challenge in implementing care pathways due to shortages of trained health care personnel and lack of equipment.

More, importantly the current standard care pathway for DR is also not clear or not universally adopted by all health care professions.

A recent survey of 50 Asian countries revealed that only 11 countries have some form of guideline. Of these, 9 are for general diabetes care and only 2 are specific to DR. This is a recurring problem in health care where a lack of clear understanding and guidance within specific contexts hinders the development of health policies, structuring of programmes and the monitoring of their implementation.

A comprehensive guideline on DR screening should include recommendations on:

• When to conduct the first and subsequent screenings
• The criteria that need to be applied for referral and the screening process
• The personnel and equipment to be used.

The International Council of Ophthalmology (ICO) has developed specific DR screening guidelines to suit context-specific needs from high to low resource settings. A comprehensive guideline does not necessarily equate to having a robust screening programme, but it serves as the cornerstone for establishing a well-structured and cost-efficient national screening programme.

In your own setting, do you have a functioning DR screening guideline that has been widely adopted and implemented? If not, what can be done locally to screen and manage diabetic retinopathy?