What is the recommended screening for diabetic-related changes in the eye?

Screening for Diabetic Retinopathy

All patients with type 2 diabetes require a dilated comprehensive eye examination by an ophthalmologist or optometrist immediately at diagnosis, while type 1 diabetes patients need their first exam within 5 years of diagnosis. 1

Initial Screening Timing

Type 2 Diabetes

• Perform dilated comprehensive eye examination at the time of diabetes diagnosis because patients may have had years of undiagnosed hyperglycemia and significant retinopathy may already be present 1, 2
• The examination must include visual acuity testing and dilated retinal examination 1

Type 1 Diabetes

• Schedule initial dilated comprehensive eye examination within 5 years after diabetes onset 1, 2
• This delayed timeline is justified because retinopathy typically requires at least 5 years of hyperglycemia to develop 1, 2
• Generally not necessary before age 10 years, though clinical judgment should guide individual cases 2

Follow-Up Examination Frequency

Patients Without Retinopathy

• Annual dilated retinal examinations are the standard recommendation 1, 2
• Every 1-2 years may be acceptable if there is no retinopathy on one or more annual exams AND glycemia is well controlled 1, 2
• This less frequent interval is cost-effective and supported by evidence showing minimal risk of significant retinopathy development within 3 years after a normal examination in well-controlled patients 1

Patients With Retinopathy

• At least annual examinations are mandatory if any level of diabetic retinopathy is present 1, 2
• Mild retinopathy: annual examinations 1
• Moderate retinopathy: every 3-6 months 1
• Severe retinopathy: every 3 months 1
• More frequent than scheduled examinations are required if retinopathy is progressing or sight-threatening 1, 2

Pregnancy-Related Screening

Women with preexisting type 1 or type 2 diabetes planning pregnancy require comprehensive eye examination before conception or in the first trimester, then monitoring every trimester and for 1 year postpartum. 1

• The risk is substantial: 52.3% prevalence of any retinopathy and 6.1% prevalence of proliferative diabetic retinopathy in early pregnancy among those with preexisting diabetes 1, 2
• Progression rates per 100 pregnancies: 15.0 for new retinopathy development, 31.0 for worsened nonproliferative retinopathy, and 6.3 for progression to proliferative disease 1
• Gestational diabetes does NOT require special retinal screening during pregnancy as these patients are not at increased risk 1, 2

Alternative Screening Modalities

Retinal photography with remote reading by trained eye care providers or FDA-approved artificial intelligence systems are appropriate screening strategies when access to ophthalmologists/optometrists is limited. 1, 2

Key Requirements for Telemedicine Programs

• Must provide pathways for timely referral for comprehensive eye examination when abnormalities are detected 1, 2
• High-quality fundus photographs can detect most clinically significant diabetic retinopathy 1
• In-person exams remain necessary when photos are of unacceptable quality or for follow-up of detected abnormalities 1
• These are screening tools, not substitutes for dilated comprehensive eye exams 1

Critical Referral Triggers

Immediate referral to an ophthalmologist experienced in diabetic retinopathy management is required for: 1, 2

• Any level of diabetic macular edema
• Moderate or severe nonproliferative diabetic retinopathy
• Any proliferative diabetic retinopathy

Important Clinical Pitfalls

Rapid Glycemic Improvement

• Assess retinopathy status before intensifying glucose-lowering therapy, particularly with GLP-1 receptor agonists 2
• Rapid reductions in A1C can cause initial worsening of retinopathy 1, 2
• This is especially concerning in pregnancy when intensive glycemic management is implemented in patients with existing retinopathy 1

Systemic Risk Factor Management

• Optimize glycemic control to reduce risk or slow progression of retinopathy 1, 2
• Optimize blood pressure control to reduce risk or slow progression of retinopathy 1, 2
• Control of blood lipids may also prevent or delay progression 1

Common Barriers to Screening

• Approximately 30% of diabetic patients do not receive recommended annual eye examinations 3, 4
• The most common reasons are procrastination, lack of awareness of the need, and financial issues 4
• Physicians must actively educate patients about the necessity of eye examinations and document this counseling 4