Diabetic Retinopathy Management Guidelines

Rahul Chakrabarti; C Alex Harper; Jill Elizabeth Keeffe


Expert Rev Ophthalmol. 2012;7(5):417-439. 

In This Article

Materials & Methods

A structured search was conducted to identify existing DR guidelines for patients with Type 1 and 2 diabetes. This was performed by searching electronic databases: MEDLINE, CINAHL, PubMed, Web of Science, Scopus and the Cochrane library. The following websites were also searched: WHO, the National Health and Medical Research Council (NHMRC), International Agency for Prevention of Blindness (Vision 2020), International Council of Ophthalmology, NICE, National Screening Committee (NSC), ClinicalTrials.gov, National Guideline Clearing house and Google Scholar. Titles, abstracts and articles were searched for the terms 'diabetic retinopathy', 'screening' and 'clinical guidelines'. Guidelines were assessed adapting domain concepts outlined in the Conference of Guideline Standardisation[6] and the Appraisal of Guidelines for Research and Evaluation Instruments.[7] However, the purpose of the review was not to 'score' guidelines as such, but rather to compare the content in each with the highest level of evidence.

Inclusion Criteria

The criteria for inclusion were based on research questions set by the NHMRC multidisciplinary expert panel working group for guideline development. Guidelines included for this review were required to meet the following component criteria: included the following key components related to DR: epidemiology, stages of DR, detection and management; provided evidence-based recommendations and developed by an expert panel or an authority commissioned by a national authority.

The authors excluded guidelines that were published in a language other than English, content that has been based upon another published guideline or those from the same authority that have been superseded by updated editions.

Included Guidelines

The database search revealed 123 references, 18 of which were identified as clinical practice guidelines. A further 14 guidelines were identified through an internet search. In total, 32 guidelines for aspects of DR management were available. For the purposes of this review, the authors have included all guidelines that have addressed all key component criteria. (Table 1). Nine guidelines were excluded from the final list as they did not satisfy all inclusion criteria (Appendix A). Eleven guidelines were published in languages other than English (Appendix B). Thus, of the eligible 21 guidelines, 12 (57%) included all key components; 17 (81%) discussed epidemiology; 17 (81%) discussed stages of retinopathy; 20 (95%) discussed detection of DR; 16 (76%) discussed management and 20 (95%) made evidence-based recommendations. It must be acknowledged that some of the excluded guidelines provided specific information pertaining to certain aspects of DR management (e.g., patients with Type 1 diabetes or frequency of examination). Accordingly, relevant aspects of these excluded guidelines have been compared where appropriate.

Overall, the international guidelines all promote early diagnosis, and substantiate recommendations based on evidence. However, as will be discussed, for certain aspects of DR management, there are large variations between guidelines. Furthermore, many of the recommendations assume access to highest-level treatment infrastructure. Largely, there are several issues in simply implementing these guidelines in an environment where access to healthcare service and infrastructure is limited. This was highlighted by only six guidelines (16%) being published in developing countries. This review appraises the current evidence for management of DR, and comments on the strengths and limitations for adaptation of this evidence in the context of low-resource settings.