Original Title: Complicaciones de la diabetes. Retinopatía diabética

Authors' objectives: The aim of this review is to assess the available information related to when DR screening should commence, the screening frequency in diabetic patients without DR, and the degree of agreement in the interpretation of retinal images among different health care professionals, with the aim to establish general criteria to allow a possible screening programme in our environment.

Authors' results and conclusions: To answer the question regarding the moment to start DR screening, the recommendations of ten CPG are included, and wherever possible the evidence in which these recommendations are based. Six CPG with recommendations for type 1 and type 2 diabetic patients, one CPG for type 2 diabetic patients, and three CPG for type 1 diabetic children and adolescents were identifi ed. The evidence in which these recommendations are based, establish the need to perform a first DR screening in type 2 diabetic patients at the time of the diagnosis. For type 1 diabetic patients, the recommendations differ among the different CPG; this is so, that the moment for the fi rst DR screening ranges between 9 to 15 years old, depending on the CPG; and/or 2 to 5 years after the diagnosis. Regarding the screening frequency, we include the conclusions from the Danish Health Technology Assessment systematic review and the results from three cohort studies. The first one indicates the possibility of less frequent screening in older type 2 diabetic patients with a good glycemic control, and in type 2 diabetic patients with mild DR or no DR, with a good blood glucose and blood pressure control. Two of the cohort studies explore the annual incidence of DR in type 1 and type 2 diabetic patients. Both studies, despite of having a similar design are not comparable, mainly due to differences in the study population characteristics, and the different assistential levels (primary care vs. secondary care); even so, the recommended screening periods are similar in both studies, every 3 to 4 years, except in the case of type 2 diabetic patients with risk factors and no DR, where one of the studies recommends continuing with annual screening. The third cohort study, explores the incidence of DR over a period of 10 years, its results support the conclusions from the two previous studies. In relation to the reading of retinal images from nonmydriatic cameras, we include the results from four agreement studies. Three studies assess image interpretation by different health care professionals after providing them with specifi c training. Two of the studies, show substantial degree of agreement between general practitioners and ophthalmologists (kappa>0.60). The third study shows lower degrees of agreement among all the different health care professionals, but it is important to mention that this last study, is not applicable to our environment, not only because general practitioners are not included among its participants, but also because the image classifi cation after the initial assessment is different. Finally the fourth study, also shows substantial degree of agreement (kappa>0.60), but it presents as a limitation a low DR prevalence in the study sample. There is no consensus regarding the appropriate moment to perform the first DR screening in type 1 diabetic patients, and different CPG vary in their recommendations. In such a way that, the first screening in type 1 diabetic patients can start between 9 to 15 years old, and/or 2 to 5 years after the diagnosis of diabetes. In type 2 diabetic patients, the first DR screening must be performed at the moment of the diagnosis. In diabetic patients with no DR, the screening period could be extended to time intervals exceeding one year. But in any case, this interval should not be longer than 3 years, in type 2 diabetic patients with no DR and no risk factors. And no longer than 4 years, in type 1 diabetic patients with no DR. In our environment the general practitioners, given prior and specific training to read retinal images, can perform DR screening by reading retinal images obtained with nonmydriatic retinal camera.

Authors' methods: Search strategy: A search of studies published between 2001 and November 2008 was executed in the following databases: Medline, Embase, Lilacs, CRD. A search in Trip Database was also executed to identify clinical practice guidelines (CPG). A manual search was also undertaken from the previously identified references. Selection criteria: Studies and systematic reviews that looked into the annual incidence of DR in the diabetic population, and studies that assessed the degree of agreement among different health care professionals were selected. CPG that included recommendations related to the DR screening were also chosen.

Project Status: Completed

Year Published: 2009

URL for published report: https://www.iacs.es/wp-content/uploads/2017/04/280_Retinopat%C3%ADa_diabetes_IACS.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Health Sciences Institute in Aragon (IACS)

Contact Address: Avda, San Juan Bosco, 13, planta 2

Contact Name: María Pilar Calvo Pérez

Contact Email: direccion.iacs@aragon.es