• AAO PPP Retina/Vitreous Panel, Hoskins Center for Quality Eye Care
    Retina/Vitreous

    Introduction

    These are summary benchmarks for the Academy's Preferred Practice Pattern® (PPP) guidelines. The Preferred Practice Patterns series of guidelines has been written on the basis of three principles.

    • Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
    • Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
    • Each recommendation should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects the best evidence available.

    Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. They physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

    The Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

    For each major disease condition, recommendations for the process of care, including the history, physical exam and ancillary tests, are summarized, along with major recommendations for the care management, follow-up, and education of the patient. For each PPP, a detailed literature search of PubMed and the Cochrane Library for articles in the English language is conducted. The results are reviewed by an expert panel and used to prepare the recommendations, which are then given a rating that shows the strength of evidence when sufficient evidence exists.

    To rate individual studies, a scale based on the Scottish Intercollegiate Guideline Network (SIGN) is used. The definition and levels of evidence to rate individual studies are as follows:

    • 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)

    Recommendations for care are formed based on the body of the evidence. The body of evidence quality ratings are defined by Grading of Recommendations Assessment, Development and Evaluation (GRADE) as follows:

    • Good quality (GQ): Further research is very unlikely to change our confidence in the estimate of effect
    • Moderate quality (MQ): Further research is likely to have an important impact on our confidence in the estimage of effect and may change the estimate
    • Insufficient quality (IQ): 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

    The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The ratings of importance are divided into three levels.

    • Level A, defined as most important
    • Level B, defined as moderately important
    • Level C, defined as relevant but not critical

    Key recommendations for care are defined by GRADE as follows:

    • Strong recommendation (SR): Used when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do not
    • Discretionary recommendation (DR): 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

    In PPPs prior to 2011, the panel rated recommendations according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The ratings of importance are divided into three levels.

    • Level A, defined as most important
    • Level B, defined as moderately important
    • Level C, defined as relevant but not critical

    The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The "ratings of strength of evidence" also are divided into three levels.

    • Level I includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
    • Level II includes evidence obtained from the following:
      • Well-designed controlled trials without randomization
      • Well-designed cohort or case-control analytic studies, preferably from more than one center
      • Multiple-time series with or without the intervention
    • Level III includes evidence obtained from one of the following:
      • Descriptive studies
      • Case reports
      • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review) 

    This former approach, however, will eventually be phased out as the AAO adopted the SIGN and GRADE rating and grading systems.

    The PPPs are intended to serve as guides in patient care, with greatest emphasis on technical aspects. In applying this knowledge, it is essential to recognize that true medical excellence is achieved only when skills are applied in such a manner that the patients' needs are the foremost consideration. The AAO is available to assist members in resolving ethical dilemmas that arise in the course of practice. (AAO Code of Ethics)

    Initial and Follow-up Evaluation

    Initial Exam History (Key elements)

    • Duration of diabetes (II++, GQ, SR)
    • Past glycemic control (hemoglobin A1c) (II++, GQ, SR)
    • Medications (II++, GQ, SR)
    • Medical history (e.g., obesity, renal disease, systemic hypertension, serum lipid levels, pregnancy) (II++, GQ, SR)
    • Ocular history (II++, GQ, SR)

    Initial Physical Exam (Key elements)

    • Visual acuity (III, GQ, SR)
    • Slit-lamp biomicroscopy (III, GQ, SR)
    • Measurement of IOP (III, GQ, SR)
    • Gonioscopy before dilation when indicated (for neovascularization of the iris or increased IOP) (III, GQ, SR)
    • Pupillary assessment for optic nerve dysfunction
    • Thorough funduscopy including stereoscopic examination of the posterior pole (III, GQ, SR)
    • Examination of the peripheral retina and vitreous, best performed with indirect ophthalmoscopy or with slit-lamp biomicroscopy (III, GQ, SR)

    Diagnosis

    • Classify both eyes as to category and severity of diabetic retinopathy and macular edema. (III, GQ, SR) Each category has an inherent risk for progression and is dependent on adherence to overall diabetes control.

    Follow-up History

    • Visual symptoms (II+, GQ, SR)
    • Systemic status (pregnancy, blood pressure, serum cholesterol, renal status) (III, GQ, SR)
    • Glycemic status (hemoglobin A1c) (III, GQ, SR)

    Follow-up Physical Exam

    • Visual acuity (III, GQ, SR)
    • Measurement of IOP (III, GQ, SR)
    • Slit-lamp biomicroscopy with iris examination (III, GQ, SR)
    • Gonioscopy (preferably before dilation when iris neovascularization is suspected or present or if IOP is elevated) (III, GQ, SR)
    • Stereoscopic examination of the posterior pole after dilation of the pupils (III, GQ, SR)
    • Examination of the peripheral retina and vitreous when indicated (III, GQ, SR)
    • OCT imaging when appropriate (III, GQ, SR)

    Ancillary Tests

    • Optical coherence tomography can be used to quantify retinal thickness, monitor macular edema, identify vitreomacular traction, and detect other forms of macular disease in patients with diabetic macular edema. (III, GQ, SR) Decisions to repeat anti-VEGF injections, change therapeutic agents (e.g., use of intraocular corticosteroids), initiate laser treatment, or even consider vitrectomy surgery are often based in part on OCT findings.
    • Fundus photography may be useful for documenting the presence of NVE and NVD, the response to treatment, and the need for additional treatment at future visits. (III, IQ, SR)
    • Fluorescein angiography is used as a guide for treating CSME and as a means of evaluating the cause(s) of unexplained decreased visual acuity. (III, IQ, SR) Angiography can identify macular capillary nonperfusion or sources of capillary leakage resulting in macular edema as possible explanations for visual loss. (III, IQ, SR)
    • Fluorescein angiography is not routinely indicated as a part of the examination of patients with diabetes. (III, GQ, SR)
    • Ultrasonography enables assessment of the status of the retina in the presence of a vitreous hemorrhage or other media opacity, and may be helpful to define the extent and severity of vitreoretinal traction, especially on the macula of diabetic eyes. (III, GQ, SR)

    Patient Education

    • Discuss results of exam and implications
    • Encourage patients with diabetes but without diabetic retinopathy to have annual dilated eye exams (II++, GQ, SR)
    • Inform patients that effective treatment for diabetic retinopathy depends on timely intervention, despite good vision and no ocular symptoms
    • Educate patients about the importance of maintaining near-normal glucose levels and near-normal blood pressure and lowering serum lipid levels (III, GQ, SR)
    • Communicate with the attending physician, e.g., family physician, internist, or endocrinologist, regarding eye findings (III, GQ, SR)
    • Provide patients whose conditions fail to respond to surgery and for whom further treatment is unavailable with proper professional support and offer referral or counseling, rehabilitative, or social services as appropriate (III, GQ, SR)
    • Refer patients with reduced visual function for vision rehabilitation (see www.aao.org/smart-sight-low-vision) and social services (III, GQ, SR)

    Management Recommendations

    Management Recommendations for Patients with Diabetes

    • Severity of Retinopathy Presence of
      Macular Edema
      Follow-up
      (Months)
      Panretinal
      Photocoagulation
      (Scatter)
      Laser
      Focal and/or
      Grid Laser*
      Intravitreal Anti-
      VEGF Therapy
      Normal or minimal NPDR No 12 No No No

      Mild NPDR

      No

      ME

      CSME

      12

      4-6

      1*

      No

      No

      No

      No

      No

      Sometimes

      No

      No

      Sometimes

      Moderate NPDR


      No

      ME

      CSME

      6-12

      3-6

      1*

      No

      No

      No

      No

      No

      Sometimes

      No

      No

      Sometimes

      Severe NPDR

      No

      ME

      CSME

      4

      2-4

      1*

      Sometimes

      Sometimes

      Sometimes

      No

      No

      Sometimes

      No

      No

      Sometimes

      Non-high-risk PDR

      No

      ME

      CSME

      4

      4

      1*

      Sometimes

      Sometimes

      Sometimes

      No

      No

      Sometimes

      No

      No

      Sometimes

      High-risk PDR

      No

      ME

      CSME

      4

      4

      1*

      Recommended

      Recommended

      Recommended

      No

      Sometimes

      Sometimes

      Considered

      Usually

      Usually

      Anti-VEGF = anti-vascular endothelial growth factor; CSME = clinically significant macular edema; ME = non-clinically significant macular edema; NPDR = nonproliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy

      * Adjunctive treatments that may be considered include intravitreal corticosteroids or anti-VEGF agents (off-label use except aflibercept and ranibizumab). Data from the Diabetic Retinopathy Clinical Research Network in 2011 demonstrated that, at two years of follow-up, intravitreal ranibizumab with prompt or deferred laser resulted in greater visual acuity gain and intravitreal triamcinolone acetonide plus laser also resulted in greater visual gain in pseudophakic eyes compared with laser alone. Individuals receiving the intravitreal injections of anti-VEGF agents may be re-examined as early as one month following injection.

      † Exceptions include hypertension or fluid retention associated with heart failure, renal failure, pregnancy, or any other causes that may aggravate macular edema. Deferral of photocoagulation for a brief period of medical treatment may be considered in these cases. Also, deferral of CSME treatment is an option when the center of the macula is not involved, visual acuity is excellent, close follow-up is possible, and the patient understands the risks.