IAPB Essential List: Diabetic Retinopathy

The Essential Lists:

Screening for Diabetic Retinopathy. Photo credit: Terry Cooper

Version: Third Edition (November 2018)

Challenges to the prevention of blindness from DR

Although early identification and treatment can prevent almost all blindness from Diabetes Retinopathy (DR), about 50% of people with Diabetes Mellitus (DM) are unaware of their condition, alternatively, that they should have their vision examined regularly, and / or are asymptomatic during the early stages of DR, and fail to access timely care. Further their opportunities to access to care may be limited. In many Low-and-Middle-Income (LMIC) countries, and in remote locations, the health personnel, technology, and systems of care needed to identify and effectively treat DR are often lacking. Screening should obviously be confined to where treatments are possible. Even where surgical interventions are not yet available, early non-invasive treatments (i.e., pharmacological, intensive blood glucose control) need to be explored and their implementation facilitated. Such applications have shown promise in mitigating the deterioration of DR.

An integrated approach to DM

This List recognises a multifaceted approach is required to reduce the risk of developing DR and slow its progression as described in “Strengthening health systems to manage diabetic eye disease: Integrated care for diabetes and eye health“. This document calls for a patient-centred approach and collaboration across the diabetes and eye health sectors.

The figure below describes the services for DR screening monitoring and treating at various levels of the health system.

Essential List for DR – Addendum

Description Standard List Category or locally purchased (L) Essential (E) or Desirable (D) Quantity Required for 5000 people with DM per 100000 people
Equipment
Fundus Camera Diagnostic / Fundus/retinal Cameras / Non-Mydriatic Portable E A Non-Mydriatic Camera does not usually need pupil dilation, thus faster and more comfortable for people than methods that require dilation. Thus is more suited to screening Most screening programmes use non-mydriatic digital cameras whether or not the pupils are dilated because these offer better image quality through smaller pupils. 1
Software & Laptop to use with Fundus Camera L E for image storage, preferably also for patient records and recall system 1
Slitlamp biomicroscope Diagnostic / Slit Lamps / Static E As an alternative/ adjunct/ back-up to a non-mydriatic camera 1
Noncontact biconvex indirect lenses to use with the slitlamp: 90D or 78D or 60D lens Diagnostic / Diagnostic Ophthalmic Lenses / Fundus Lenses E At least one lens is needed to view the retina using a slitlamp (90 D for screening, 78 D for more magnification) 1
Adapter for digital camera for use with slit lamp Purchase with Slit lamp D As an alternative/ adjunct/ back-up to an indirect ophthalmoscope image or non-mydriatic camera Caution: different adapters are required for different slitlamps 1
Adapter for use of a smart phone to capture images Purchase with Slit Lamp D As an alternative/ adjunct/ back-up to an indirect ophthalmoscope image or non-mydriatic camera Caution: different adapters are required for different smartphones 1
Indirect Ophthalmoscope if possible, with wireless capability to take digital images Diagnostic / Ophthalmoscopes  / Indirect E Dilated exam (preferably with digital images) as an alternative/ adjunct/ back-up to a non-mydriatic camera or slitlamp (optional for screening, panoramic view, low magnification) 1
20D or 28D lens Diagnostic / Diagnostic Ophthalmic Lenses / Fundus Lenses E At least one lens is needed to view the retina using an indirect ophthalmoscope 1
Direct ophthalmoscope Direct Ophthalmoscope E Dilated exam as an alternative/ adjunct/ back-up if a non-mydriatic camera, slitlamp or indirect ophthalmoscope are not available. 1
Vision charts (distance and near) Vision Charts E VA assessment is useful in conjunction with retinal examination 1
Pinhole Occluder Refractive Service / Occluders E VA assessment is useful in conjunction with retinal examination 1
Glucometer with test strips or test for HbA1c Sphygmomanometer OGTT equipment D If DR services are not integrated with general diabetes services 1
Supplies/Consumables
Dilating eye drops E To dilate pupils if required for retinal photography /examination As required
Tropicamide 1% 5ml /eye Drops or alternative e.g. Cyclopentolate HCl 1% 5ml Eye Drops (Mydriatic) E Pharmaceuticals / Mydiatrics / Dilating Drops E Tropicamide is faster acting, and dilation is of shorter duration than Cyclopentalate As required
Phenylephrine HCl 2.5% Eye Drops (Mydriatic) Pharmaceuticals / Mydiatrics / Dilating Drops E Phenylephrine can be used in conjunction with tropicamide to increase the speed and amount of dilation, especially with dark irises As required
Equipment
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required for 1700 people with DM per 100000 people
Large field conventional fundus camera Fundus Cameras D For mydriatic retinal photography in reference centres Non-mydriatic cameras are used either with staged mydriasis, routine mydriasis over the age of 50 years or routine mydriasis in all age groups. 1
Three-mirror contact lens used with slit lamp Laser Lens D Stereoscopic and high-resolution images of the macula (evaluation of macular oedema). 1
Optical Coherence Tomography (OCT) OCT D Most sensitive method to identify sites and severity of retinal oedema 1
Supplies/Consumables
Proparacaine 0.5% or Amethocaine Hcl 0.5% Eye Drops 5ml (or similar topical anaesthetic) Pharmaceuticals / Local Anaesthetic Preps E As required
Methylcellulose drops e.g. Viscotears, Hypomellose 2.5% Goniogel E a coupling agent for three mirror contact lens As required
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required for 500 people with DM  per 100000 people
Equipment - Lasers
Green laser (532 nm), frequency-doubled Nd:YAG or argon laser (514 nm using 50-100ms pulse duration) Green Laser E Argon Green laser, a direct/focal laser, is still commonly used for single burns. There is no good evidence that modern laser systems are more effective than the argon (ETDRS) but they appear to have fewer adverse effects Its portability is a further benefit 1
Infrared laser (810 nm Krypton red) or diode laser Infrared laser D Causes deeper burns with a higher rate of patient discomfort, but tend to be cheaper, is effective, and requires less maintenance. 1
Pattern Scanning Laser with different wavelengths - green (532nm) or yellow laser (577 nm) using 20-30ms pulse duration, spot size (400 microns) If hazy media, use diode red laser (814 nm). D Pattern Scanning Lasers with predetermined multi-spot treatment cascade for PRP or grid. Produces multiple spots making it less tedious and time consuming, and more comfortable for the patient. 1
Light focal laser - minimise lesion intensity and pulse duration (10-50ms) D ‘Light’ refers to using lasers at lower power and producing less severe burns:Minimum intensity photocoagulation (MIP) 1
Subthreshold micropulse diode laser - low-intensity, longer wavelength shorter duration pulses D Produces less retinal damage and is safer, less likely to produce macula oedema. Shows promise in focal laser for DMO but there are very few data on use in PRP 1
Delivery systems Some lasers have built in delivery systems
Slitlamp delivery system  Diagnostic / Slit Lamps / Static E 1
Indirect delivery system Indirect Ophthalmoscope D an indirect ophthalmoscope and lens is used to focus the laser light onto the retina, particularly for patients where pain requires the use of an anaesthetic E In situations where travel by patients is often physically and financially impossible, outreach with a binocular indirect equipped with laser and fibreoptic cable enables access to definitive treatment. It is more affordable in resource-constrained countries. 1
Endolaser probe (direct delivery) D 1
Laser contact lenses Diagnostic / Diagnostic Ophthalmic Lenses / Fundus Lenses E A contact lens is used to focus a beam of laser light onto the retina and provide magnification wide angle contact lenses  are useful for panretinal photocoagulation because these provide easy access to the post-equatorial region which is difficult to visualize with a three mirror lens 1
Monitor to view retinal images during laser treatment L D 1
Fundus Fluorescein Angiography (FFA) including retina camera and image net D FFA is not needed to diagnose DME or PDR, these are diagnosed by a clinical exam. FFA can be used as a guide for treating DME and to evaluate cause(s) of unexplained decreased VA As required
Sub-Tenons Local Anaesthesia
Equipment
Lid speculum (eg Kratz Barraquer) > E As required
Small forceps (eg Hoskins-style notched tip) E As required
Curved blunt-tipped spring scissors (eg blunt Westcott) E As required
Sub-Tenon’s Anasthesia Cannula 19g, curved, flattened and blunt tipped Alternative curved blunt-tipped cannula (eg. Stevens) Kumar-Dodds plastic cannula, Greenbaum or “ultrashort” cannula As required
Supplies/Consumables
Povidone Iodine 4% Pharmaceuticals > Antibiotics E As required
Local anesthetic drops proxymetacaine 0.5% or oxybuprocaine 0.4% Pharmaceuticals / Local Anaesthetic Preps E As required
Lignocaine hydrochloride 2% Pharmaceuticals / Local Anaesthetic Preps E Patients on Warfarin 4mls of 2% Lignocaine (no Adrenaline)
Hyalase (Hyaluroneidase) 1500IU vial Pharmaceuticals > Others Alternative to Lignocaine – Mixed in with the anaesthetic. It allows the local anaesthetic to penetrate through the tissue planes more extensively. · 2% lignocaine+150 iu hyauronidase: ±45 minutes of surgical anesthesia. · 2% plain lignocaine, 0.5% plain bupivacaine, and 150 iu hyaluronidase:±60–90 minutes of surgical anesthesia As required
0.5% or 1% Ropivacaine (Naroprin) If a longer procedure is expected mix · 0.5% Ropivacaine in a 50:50 with the 2% Lignocaine. · 1% ropivacaine+150 iu hyaluronidase:±90–120 minutes of surgical anesthesia As required
5ml / 10ml Syringe Consumables / Syringes / Needles E As required
25g / 27g Needles Consumables / Syringes / Needles E As required
Eye pads and tape L D As required
FFA D
Inkjet Cartridge, Plastic Cover Photo Paper, Printing paper L As required
Plaster Roll L As required
Fluorescein Sodium 20% 3ml amp As required
Syringe (1cc) Consumables / Syringes / Needles As required
Syringe (5cc) Consumables / Syringes / Needles As required
Saline flush L As required
Mydriatics Pharmaceuticals / Mydiatrics / Dilating Drops As required
Sterile wipes L As required
Butterfly or cannula with the vecafix E - if FFA As required
Equipment
Lid Speculum E As required
Calipers E To mark 3.5mm behind limbus for pseudophakes and 4mm for phakic individuals As required
Pharmaceuticals
Anti-VEGF: Avastin 1.25mg (bevacizumab) (although outcomes are effective, aflibercept (and ranibizumab) are expensive and not cost-effective compared with bevacizumab). Avastin may not, however, be an option for some low-middle income settings (cost and human resources implications) E /D – context (and resources (Trained personnel and equipment) dependant Focal laser being a preferred choice if anti-VEGF is not available Avastin is delivered via typically supero-temporal or infero-temporal) intravitreal injections. Needs refrigeration and to be kept sterile. Compounding pharmacy will draw out the aliquot of 0.05. Multiple punctures are safe. See responsibly pharmaceutical compounding
Steroids: triamcinolone, a short acting steroid, which is not licensed for use in the eye, has been widely used. E /D - context dependant Steroids are unlikely to be much used at such an early stage as NPDR because of the risk of complications, but may have a role in pseudophakic patients, or in patients with macular oedema that does not respond to anti-VEGF treatment. As required
Topical Anaesthetic Pharmaceuticals / Local Anaesthetic Preps E As required
Antibiotic drops Pharmaceuticals > Antibiotics For 3 days after OR stat dose after As required
Diamox 250mg tables and iopidine drops To reduce a sudden rise in pressure As required
Supplies/Consumables
1ml (Tuberculin) syringe Consumables / Syringes / Needles E If not already preloaded syringe then a drawing up needle is required As required
27g or 30g needle Consumables / Syringes / Needles E As required
Sterile Masks E Vital – post-injection endophathlmitis typically has a different bacterial profile vs post-cataract endophthalmitis, most notably being more respiratory pathogens involved. Practitioner should not breathe on patient and patient should not talk during injection As required
Povidone iodine 5% or 10% solution 200 ml or alternative cleaning agent if allergic Pharmaceuticals > Antibiotics E In conjunctival sac for minimum of 3 minutes prior to procedure As required
A sterile dressing kit with sterile gauze and a tray for the iodine. L D As required
Iodine surgical scrub, hand towels and sterile gloves L D As required
A sterile drape is used to capture the lashes L this is not used in some centres (e.g. in USA). If a drape is not pre-cut scissors are required As required
Cotton Tips L E As required
SURGERY FOR DR – See Separate VITREORETINAL List
Publication / Manual Published by Where available
Diabetic Retinopathy Treatment & Management Medscape https://emedicine.medscape.com/article/1225122-treatment#aw2aab6b6b1aa
ICO Guidelines for Diabetic Eye Care ICO http://www.icoph.org/resources/309/ICO-Guidelines-for-Diabetic-Eye-Care-available-in-English-Chinese-French-Portuguese-Serbian-Spanish-and-Vietnamese--.html
Diabetic Retinopathy http://www.diabeticretinopathy.org.uk/index.html
Diabetic retinopathy for the comprehensive ophthalmologist.  Authors: Raj Maturi, Jonathan D. Walker, Robert Chambers, D.O. 2016 Deluma Medical Publishers Download Diabetic retinopathy for the comprehensive ophthalmologist.
IDF Diabetes Eye Health – A guide for health professionals, 2015 IDF and Fred Hollows Foundation https://www.idf.org/our-activities/care-prevention/eye-health/eye-health-guide/1-item1.html
’Strengthening health systems to manage diabetic eye disease: Integrated care for diabetes and eye health’ a multifaceted approach is required to reduce the risk of developing DR and slow its progression Endorsed by International Agency for the Prevention of Blindness (IAPB), International Council of Ophthalmology (ICO), World Council of Optometry (WCO) and International Diabetes Federation (IDF) https://www.iapb.org/wp-content/uploads/DR_Statement_FINAL_Online.pdf
’Global Diabetic Retinopathy Advocacy Initiative. Integrated care for diabetes and eye health: A global compendium of good practice. Melbourne, Australia, 2018 Multi agency initiative https://www.iapb.org/resources/a-global-compendium-on-good-practice-integrated-care-for-diabetes-and-eye-health/
’ADAPTATION FOR KENYA: Guidelines for Screening and Management of Diabetic Retinopathy in Kenya. These Guidelines for the screening and management of diabetic retinopathy in Kenya 2017 edition MOH Kenya http://www.health.go.ke/wp-content/uploads/2017/11/Guidelines-for-Screening-and-Management-of-Diabetic-Retinopathy-in-Kenya.pdf
Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs. Mwangi N, Gachago M, Gichangi M, Gichuhi S, Githeko K, Jalango A, Karimurio J, Kibachio J, Muthami L, Ngugi N, Nduri C, Nyaga P, Nyamori J, Zindamoyen ANM, Bascaran C, Foster A Implement Sci. 2018 Jun 15;13(1):81. doi: 10.1186/s13012-018-0773-2. PubMed PMID: 29903039; PubMed Central PMCID: PMC6003001.
Effectiveness of peer support to increase uptake of retinal examination for diabetic retinopathy: study protocol for the DURE pragmatic cluster randomized clinical trial in Kirinyaga, Kenya. Mwangi N, Ng'ang'a M, Gakuo E, Gichuhi S, Macleod D, Moorman C, Muthami L, Tum P, Jalango A, Githeko K, Gichangi M, Kibachio J, Bascaran C, Foster A. BMC Public Health. 2018 Jul 13;18(1):871. doi: 10.1186/s12889-018-5761-6. PubMed PMID: 30005643; PubMed Central PMCID: PMC6044026.
East African Economics and Implementation Group (EAEIG). Cost and affordability of non-communicable disease screening, diagnosis and treatment in Kenya: Patient payments in the private and public sectors. Subramanian S, Gakunga R, Kibachio J, Gathecha G, Edwards P, Ogola E, Yonga G, Busakhala N, Munyoro E, Chakaya J, Ngugi N, Mwangi N, Von Rege D, Wangari LM, Wata D, Makori R, Mwangi J, Mwanda W PLoS One. 2018 Jan 5;13(1):e0190113. doi: 10.1371/journal.pone.0190113. eCollection 2018. PubMed PMID: 29304049; PubMed Central PMCID: PMC5755777
Predictors of uptake of eye examination in people living with diabetes mellitus in three counties of Kenya. Mwangi N, Macleod D, Gichuhi S, Muthami L, Moorman C, Bascaran C, Foster A. Trop Med Health. 2017 Dec 21;45:41. doi: 10.1186/s41182-017-0080-7. eCollection 2017. PubMed PMID: 29299019; PubMed Central PMCID: PMC5740562

IAPB wishes to acknowledge and thank the following experts and organisations for their input and support in compiling this list:

  • Richard Le Mesurier, Medical Director, The Fred Hollows Foundation
  • Anthony Hall, Consultant Ophthalmologist Newcastle Eye Hospital, Australia (formerly Head of Dept, KCMC / CBM)
  • Nick Kourgialis, Vice President at Helen Keller International
  • Tien-Yin Wong, Chair for ICO Working Group on Diabetic Eye Diseases
  • Hugh Taylor, President for ICO, Former Chair ICO Working Group on Diabetic Eye Diseases
  • Serge Resnikoff, Member ICO Working Group on Diabetic Eye Diseases
  • Peter Scanlon, Clinical Director, Diabetic Retinopathy Screening Programme UK and affiliated with the Gloucestershire NHS Trust
  • David S. Friedman, Senior Ophthalmologist and Eye Health Technical Advisor, HKI
  • Rènée du Toit, Independent Eye Health Consultant
  • Philip Hoare, IAPB Standard List & Procurement Manager
  • Vishnu Prasad, Aurolab-Aravind Eye Care System
  • Thulasiraj Ravilla, LAICO-Aravind Eye Care System
  • Vijay Kumar, LAICO-Aravind Eye Care System
  • Kim Ramasamy, Aravind Eye Hospital (Madurai) – Aravind Eye Care System
  • Praveen Raja, Aurolab-Aravind Eye Care System
  • Giridharan, Aurolab-Aravind Eye Care System
  • Naresh Babu Kannan, Aravind Eye Hospital (Madurai) – Aravind Eye Care System
  • Anand Rajendran, Aravind Eye Hospital (Madurai) – Aravind Eye Care System
  • Brandon Ah-Tong, Global Lead, Global Advocacy, The Fred Hollows Foundation
  • Jennifer Gersbeck, Director, Global Partnerships and Advocacy, The Fred Hollows Foundation & Chair of IAPB Diabetic Retinopathy Working Group
  • Belma Malanda, Senior Programs Manager, International Diabetes Federation
This list also reflects the procedures and requirements outlined in the ICO Guidelines for Diabetic Eye Care. Photo credit: Screening patient for diabetic retinopathy, Mulago Hospital, Kampala, Uganda by Terry Cooper for the #EyeCareForAll Photo Competition held for World Sight Day 2015

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