Diabetic Retinopathy Management Protocols for Optometry
By Paul Chous, MA, OD, FAAO, Dorothy Hitchmoth, OD, FAAO, and Bobby “Chip” Wood, OD
Originally published in the July 2023 issue of Review of Optometry.
Dr. Chous: Unfortunately, there are not. This unmet need in our profession creates a lot of variation in patient care and, ultimately, in patient outcomes.
Dr. Wood: I couldn’t agree more. We absolutely need some basic guidelines and concrete strategies that standardize how we meet this growing patient need.
Dr. Hitchmoth: Some would argue that a dilated fundus exam and visual acuity check tick the box, but in my experience, it’s not enough. In many cases, these basics don’t give us the confidence to say that we’re doing all we can for patients.
Dr. Chous: I’ve been giving this a lot of thought this past year and I think it’s helpful to look at the fundamentals of diabetic retinopathy management across broad categories. We need to 1) detect, 2) grade, 3) assess risk, 4) manage, and 5)support.
Dr. Wood: As basic as this sounds, it can be a tall order. Grading and assessing risk require a lot of skill and time, and are arguably subjective.
Dr. Hitchmoth: Subjectivity is a big part of the problem. What’s needed is a blueprint that provides some guidance on putting the puzzle pieces together.
We need to 1) detect, 2) grade, 3) assess risk, 4) manage, and 5) support."
Dr. Hitchmoth: I would start by saying that we need to approach diabetic retinopathy as a chronic progressive disease.
Dr. Wood: Exactly. And being a chronic progressive disease implies that you can detect it before it becomes advanced disease. The question is, how do we do this?
Dr. Chous: To begin, we need to use both structural and functional testing. OCT-A is a real game changer in structural testing. And on the functional side, although the standard of care for the assessment of vision loss due to diabetic retinopathy is high-contrast visual acuity, evidence shows it is insufficient.
Dr. Hitchmoth: I advocate for electro-diagnostic testing (ERG), preferably utilizing the additional measure of pupillometry, as in the DR score offered by the RETeval® device, since this provides a direct reading of retinal health.Dr. Chous: At the most basic level, diabetic retinopathy should be graded at the time of diagnosis and at each subsequent visit. Charting is also important and should include a record of structural retinal damage.
Dr. Wood: Quantifying retinal cell function is likewise essential. For this, I use ERG. ERG is a measure of the function of the retina, the health of the cells, and the risk of disease progression that is fast and easy to perform using the handheld RETeval device.
Dr. Chous: Here again, both structural and objective functional measures are crucial, and the two may not align, which makes things tricky.
Dr. Hitchmoth: We may be used to seeing structure first when we rely on visual acuity, but when using objective tests such as ERG, functional loss can precede identifiable structural damage. That’s important information that plays a role in how I monitor and manage the patient moving forward.
Dr. Chous: The time between retinal examinations depends on risk assessment, but no matter how severe or early the disease is, I strongly believe that multi-disciplinary resources are required to manage all diabetic retinopathy patients.
Dr. Hitchmoth: Good nutrition is also essential and is something we should emphasize with our patients.
Dr. Wood: First and foremost, we need to provide comprehensive patient education and strategies to help prevent disease progression.
Dr. Chous: To that end, it’s important to emphasize the asymptomatic nature of DR at its earliest, most treatable levels of severity and encourage patients to achieve individually optimized metabolic control in concert with their diabetes physicians.
About the Authors
Paul Chous, MA, OD, FAAO
Chous Eyecare Associates
(University Place, WA)
Dorothy Hitchmoth, OD, FAAO
Dr. Dorothy Hitchmoth, PLLC
(New London, NH)
Bobby "Chip" Wood, OD
Wood Vision Source, Coyote Optical
(San Antonio, TX)
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