Table 1. Recommendation Grading
|Study Ratings 1|
|I++||High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias|
|I+||Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias|
|I-||Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias|
|II++||High-quality systematic reviews of case-control or cohort studies|
High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
|II+||Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal|
|II-||Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal|
|III||Nonanalytic studies ( e.g., case reports, case series)|
|Evidence Ratings 2|
|G - Good quality||Further research is very unlikely to change our confidence in the estimate of effect|
|M - Moderate quality||Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate|
|In - Insufficient quality||Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain|
|Recommendation Ratings 3|
|S - Strong recommendation||Used when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do not|
|D - Discretionary recommendation||Used when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced|
- To rate individual studies, a scale based on Scottish Intercollegiate Guideline Network (SIGN) is used.
- The body of evidence quality ratings is defined by Grading of Recommendations Assessment, Development and Evaluation (GRADE). GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue.
- Key recommendations for care are defined by GRADE.
- The prevalence of diabetes, both worldwide and in the United States, is increasing; as such, the prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy (VTDR) is also expected to increase dramatically.
- Currently, only about 60% of people with diabetes have yearly screenings for diabetic retinopathy.
- People with Type 1 diabetes should have annual screenings for diabetic retinopathy beginning 5 years after the onset of their disease, whereas those with Type 2 diabetes should have a prompt examination at the time of diagnosis and at least yearly examinations thereafter.
- Maintaining near-normal glucose levels and near-normal blood pressure lowers the risk of retinopathy developing and/or progressing, so patients should be informed of the importance of maintaining good glycosylated hemoglobin levels, serum lipids, and blood pressure.
- Patients with diabetes may use aspirin for other medical indications without an adverse effect on their risk of diabetic retinopathy.
- Women who develop gestational diabetes do not require an eye examination during pregnancy and do not appear to be at increased risk of developing diabetic retinopathy during pregnancy. However, patients with diabetes who become pregnant should be examined early in the course of the pregnancy.
- Referral to an ophthalmologist is required when there is any nonproliferative diabetic retinopathy, proliferative retinopathy, or macular edema.
- Ophthalmologists should communicate both ophthalmologic findings and level of retinopathy to the primary care physician. They should emphasize to the patient the need to adhere to the primary care physician’s guidance to optimize metabolic control.
- Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents have been shown to be an effective treatment for center-involving diabetic macular edema.
- At this time, laser photocoagulation remains the preferred treatment for non-center-involving diabetic macular edema.