Y L N 2018 Clinical Practice Guidelines O

Y L N 2018 Clinical Practice Guidelines O E S U L A N Retinopathy SO R E P Chapter 30 Filiberto Altomare MD FRCSC Amin Kherani MD FRCSC Julie Lovshin MD FRCPC

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2018 Diabetes Canada CPG – Chapter 30. Retinopathy 2018 Key Changes • New information on Y • The effectiveness of local intraocular L N O pharmacological therapies in. Eimproving vision and reducing the level of diabetic US retinopathy L A N O S R E P PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Checklist üSCREEN regularly O E Y L N üDELAY onset and progression with glycemic and S U L BP control ± fibrate A R E P N O S üTREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreoretinal surgery BP, blood pressure PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Diabetic Retinopathy Most Common Cause of Blindness Among Working Age Category Proliferative Y L Retinopathy N O E Type 1 DM S U L 23% 11% 14% 15% 3% 4% A N O S R PE Type 2 DM on insulin Type 2 DM on non-insulin antihyperglycemic agents Macular Edema Klein R, et al. Diabetes Care 1992; 15(12): 1875 -91 Klein R, et al. Ophthalmology 1984; 91(12): 1464 -74 PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Increases Morbidity and Mortality • Visual loss is associated with: NLY O • • Increased falls More hip fractures L A N E S U 4 -fold increase. Sin. Omortality R E P (in type 1 diabetes) Early death PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Forms of Retinopathy 1. Macular Edema O E Y L N S U L 2. Non-proliferative and A N O Proliferative S R E P 3. Retinal Capillary Closure PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Macular Edema • Diffuse or focal vascular leakage at the macula O E Y L N S U L A N O S R PE PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Non-proliferative/Proliferative Retinopathy • Blood vessel changes • Non-proliferative O E Y L N S U L – Microaneurysms, intraretinal hemorrhage, vascular tortuosity A and vascular malformation ON S R PE • Proliferative – Abnormal vessel growth PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Retinal Capillary Closure • Seen with fluorescein angiography O E Y L N S U L A N O • Potentially blinding. S R E complication P • Currently no treatment options PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Screening for Retinopathy O E Y L N S U L A N O S R PE PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy (cont’d) O E Y L N S U L A N O S R PE PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Risk Factors for Progression • Longer duration of diabetes Y • Elevated A 1 C L N O • Hypertension E S U L • Dyslipidemia A N O • Low hemoglobin level S R E P (with type 1 diabetes) • Pregnancy • Proteinuria • Severe retinopathy itself PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Delay of the Disease 1. Glycemic control: target A 1 C ≤ 7% O E Y L N S U 2. Blood pressure control: target BP <130/80 L A N O S R E P 3. Lipid-lowering therapy: Fibrates have been shown to decrease progression and may be considered PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy DCCT: Reduction in Retinopathy with Intensive Glycemic Control Primary Prevention Secondary Intervention O E S U L 76% RRR Y L N 54% RRR A N O S R PE The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329: 977 -986. PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy UKPDS 38: Reduction in Microvascular Complications with Blood Pressure Control O E Y L N S U L A N O S R PE UKPDS. BMJ 1998; 317: 703 -713 PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy UKPDS 38: Reduction in Retinopathy with Blood Pressure Control O E Y L N S U L A N O S R PE UKPDS. BMJ 1998; 317: 703 -713 PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy ACCORD Eye: Glycemic control and Combo of fenofibrate and simvastatin reduced progression Effect Odds Ratio Glycemia 0. 67 (0. 51 - 0. 87) LY 0. 0025 Lipid 0. 60 (0. 42 S - 0. 86) 0. 0056 BP 1. 23 ON 95% CI N O E U L A (0. 84 - 1. 79) P-value 0. 29 S R Intensive glycemic PE control and combination of fenofibrate and simvastatin, but not intensive blood pressure control, reduced the rate of progression of diabetic retinopathy in this older, high-risk population. ACCORD Study Group. N Engl J Med 2010; 363(3): 233 -244. PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy FIELD: Fenofibrate reduced retinopathy requiring laser 10 HR = 0. 70 95% CI = 0. 58– 0. 85 p = 0. 0003 Cumulative risk (%) 8 6 L A N O E Y L N US Placebo O S R E P 4 2 Fenofibrate 0 0 1 2 3 4 5 6 Years from randomization FIELD Study Investigators. Lancet 2005 ; 366 (9500): 1849 -61 PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Diabetic Retinopathy CAN be Treated 1. Pan-retinal photocoagulation laser therapy Y L non-proliferative or • Reduces blindness by 90% in severe N O proliferative retinopathy SE U L Apharmacologic intervention 2. Local (intra-ocular) N O S VEGF antagonists R E P • Aflibercept, ranibizumab, bevacizumab (off-label use in Canada) improve vision 3. Surgical intervention vitrectomy PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Sight-threatening Retinopathy MUST be Y and blood L üPrevented with good blood glucose N O pressure control (±SE fenofibrate) U L A üDetected. Nthrough screening O S R therapy, anti-VEGF medications üTreated with laser E P or vitrectomy to save VISION PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 1 1. In individuals >15 years of age with type 1 diabetes, screening and evaluation for retinopathy should be Y vision care L performed annually by an experienced N O E professional (optometrist or ophthalmologist) starting S Udiabetes [Grade A, Level 1] 5 years after the onset of L A N for children and adolescents (for screening recommendation O S <15 years with type. R 1 diabetes see Type 1 Diabetes in Children E P and Adolescents chapter; for screening recommendations for pregnant women, see Diabetes and Pregnancy chapter) PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 2 2. 2018 In individuals with type 2 diabetes, screening and evaluation for diabetic retinopathy should be Y L performed by an experienced vision. Ncare professional O (optometrist or ophthalmologist) E at the time of S U A, Level 1]. The interval diagnosis of diabetes [Grade L A should be tailored to the N for follow-up assessments O S severity of the retinopathy [Grade D, Consensus]. In R E those with no. Por minimal retinopathy, the recommended interval is 1 -2 years [Grade A, Level 1] (for screening recommendations for children and adolescents with type 2 diabetes see Type 2 Diabetes in Children and Adolescents chapter) PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 3 2018 3. Screening for diabetic retinopathy should be performed by an experienced vision Y care L N professional (optometrist or ophthalmologist), either O E of retinal S in person or through interpretation U L photographs taken through dilated pupils [Grade A, A N O Level 1] or undilated. Spupils with high-resolution ultra. R E wide field imaging P [Grade D, Consensus] PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 4 2018 4. Results of eye examinations and the follow-up interval and plan should be clearly communicated to all Y L N members of the diabetes health-care team to promote O E S optimal care [Grade D, Consensus] U L A N O S R E P PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 5 5. To prevent the onset and delay the progression of Y should be diabetic retinopathy, people with diabetes L N O treated to achieve optimal control E of BG [Grade A, S U A, Level 1 A for type 2 Level 1 A for type 1 diabetes; Grade L A diabetes] and BP [Grade N A, Level 1 A for type 2 diabetes; O Sfor type 1 diabetes] Grade D, Consensus R PE BG, blood glucose; BP, blood pressure PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 6 6. Though not recommended for CVD prevention or treatment, fenofibrate, in addition. Nto LYstatin therapy, O may be used in people with type E 2 diabetes to slow S the progression of established L U retinopathy [Grade A, Level 1 A] A N O S R PE CVD, cardiovascular disease PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 7 7. Individuals with sight-threatening diabetic Yqualified retinopathy should be assessed by a L N O ophthalmologist and/or retina E specialist [Grade D, S U intervention [Grade A, Consensus]. Pharmacological L Aand/or vitrectomy [Grade A, N Level 1 A], laser therapy O S Rused to manage the diabetic Level 1 A] may be E P retinopathy PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Recommendation 8 8. Visually disabled people should be referred for low. Y[Grade D, vision evaluation and rehabilitation L N O E Consensus] S U L A N O S R PE PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Key Messages • Regular screening is important for early detection of treatable diabetic retinopathy. Screening intervals for Y individual’s L diabetic retinopathy vary according to the N O age and type of diabetes E S U Lreduces the onset and • Optimal glycemic control A N progression of sight-threatening diabetic retinopathy O S R E • Local intraocular P pharmacological therapies have the potential to improve vision and reduce the level of retinopathy PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 30. Retinopathy Key Messages for People with Diabetes • Diabetic retinopathy involves changes to retinal blood vessels that can cause them to bleed or leak fluid, distorting vision Y L N • With good glycemic control, regular eye exams and early O E treatment, the risk of vision loss is. Sreduced U L • Diabetic retinopathy often goes A unnoticed until vision loss N Owith diabetes should get a occurs, therefore people S R eye exam regularly. Discuss the comprehensive dilated E P recommended frequency with your diabetes healthcare team and experienced vision care professionals (optometrists or ophthalmologists) • Diabetic retinopathy can be treated with several therapies used alone or in combination PERSONAL USE ONLY

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Diabetes Canada Clinical Practice Guidelines LY www. guidelines. diabetes. ca – for. Nhealth-care O providers E S U L A N O 1 -800 -BANTING (226 -8464) S R E P www. diabetes. ca – for people with diabetes PERSONAL USE ONLY