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Referral and warning signs
When to refer
Refer ALL patients with diabetes for baseline dilated eye examination. Refer immediately to Ophthalmologist (RR) if any level of DR or DMO is detected, or if sudden vision loss/floaters occur.
Red flags
- Sudden loss of vision.
- Sudden onset of floaters.
- Detection of any DR (beyond background) or DMO on screening.
- Poorly controlled diabetes + visual symptoms.
Signs and symptoms
- Often asymptomatic in early stages.
- Gradual blurring of vision.
- Sudden vision loss (due to vitreous haemorrhage or retinal detachment).
- Floaters (spots/cobwebs in vision).
- Distorted vision.
- Difficulty seeing at night.
- Fluctuating vision.
- Fundoscopic signs (require dilated exam):
- - Non-Proliferative DR (NPDR): Microaneurysms, Dot & blot haemorrhages, Hard exudates (lipid deposits), Cotton wool spots (nerve fibre layer infarcts), Venous beading, Intraretinal Microvascular Abnormalities (IRMA). Classified as mild, moderate, severe.
- - Proliferative DR (PDR): Neovascularization (new, fragile blood vessels) on the disc (NVD) or elsewhere (NVE). Can lead to vitreous haemorrhage, tractional retinal detachment.
- - Diabetic Macular Oedema (DMO): Retinal thickening/swelling and/or hard exudates in the macula. Can occur at any stage of DR. Causes central vision loss.
Risk factors
- Duration of diabetes (longer duration = higher risk).
- Poor glycaemic control (high HbA1c).
- Hypertension.
- Dyslipidemia.
- Nephropathy (kidney disease).
- Pregnancy (can accelerate progression).
- Smoking.
- Obesity.
Diagnosis
Clinical assessment
Screening through regular dilated fundus examination by trained personnel (ophthalmologist, optometrist, clinical officer with training) or retinal photography.
Investigations
- Dilated Funduscopic Examination: Essential for staging DR.
- Retinal Photography: For screening and documentation.
- Optical Coherence Tomography (OCT): To detect and quantify Diabetic Macular Oedema (DMO).
- Fluorescein Angiography (FA): To visualize retinal vascular leakage, ischaemia, neovascularization (less common now with OCT).
Diagnostic criteria
Presence of characteristic retinal microvascular changes on dilated fundus examination, classified according to severity (NPDR levels, PDR, DMO).
Management
Non-pharmacological management
- Optimal Systemic Control (Crucial):
- - Tight Glycaemic Control (Target HbA1c ~7% or individualized).
- - Blood Pressure Control (<130/80 mmHg or individualized target).
- - Lipid Management (Statins).
- - Smoking Cessation.
Pharmacological treatment
- Requires Specialist Management (Ophthalmologist/Retinal Specialist): (LOC: RR)
- - Diabetic Macular Oedema (DMO):
- - Intravitreal Anti-VEGF injections: (e.g., Bevacizumab, Ranibizumab, Aflibercept). First-line for center-involving DMO.
- - Intravitreal Steroid injections/implants: (e.g., Triamcinolone, Dexamethasone implant). Alternative or adjunct.
- - Macular Laser Photocoagulation: (Focal/grid laser) for non-center involving DMO or adjunct.
- - Proliferative Diabetic Retinopathy (PDR):
- - Pan-Retinal Photocoagulation (PRP): Laser treatment applied to peripheral retina to regress neovascularization and reduce risk of severe vision loss. Mainstay of treatment.
- - Intravitreal Anti-VEGF injections: Can be used as adjunct to PRP or for complications like vitreous haemorrhage.
- - Severe NPDR: Close monitoring, consider PRP.
- - Mild/Moderate NPDR: Optimize systemic control, regular monitoring.
Monitoring
Regular dilated eye examinations. Frequency depends on level of retinopathy: - No DR / Mild NPDR: Annually. - Moderate NPDR: Every 6-9 months. - Severe NPDR: Every 3-4 months. - PDR / DMO: More frequently as determined by ophthalmologist and treatment response. Monitor systemic control (HbA1c, BP, lipids).
Complications
- Diabetic Macular Oedema (DMO).
- Vitreous Haemorrhage.
- Tractional Retinal Detachment.
- Neovascular Glaucoma.
- Severe visual impairment / Blindness.
Prevention
- Good glycaemic control from diagnosis of diabetes.
- Good blood pressure control.
- Lipid management.
- Regular dilated eye screening examinations for ALL diabetics (Type 1: within 5 yrs of diagnosis; Type 2: at time of diagnosis, then annually or as per findings).
Patient education
- Explanation of DR as a complication of diabetes.
- Critical importance of strict glucose, BP, and lipid control.
- Need for regular, lifelong dilated eye examinations even if vision is good.
- Symptoms requiring urgent review (sudden vision loss, floaters).
- Treatment options if retinopathy develops (laser, injections, surgery).
- Smoking cessation importance.
Uganda-specific notes
Increasing prevalence with rise in diabetes. Screening capacity (dilated exam, retinal photography) is limited. Access to laser photocoagulation, intravitreal injections (especially anti-VEGF), and vitrectomy restricted to specialized centres. Emphasis on systemic control and early referral vital.
Surgical Management
- Pars Plana Vitrectomy (PPV): For complications like persistent vitreous haemorrhage or tractional retinal detachment.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 20, Section 20.2.3
- Uganda Clinical Guidelines (UCG) 2023
Chapter 8, Section 8.1.3 (Diabetes Management)