Grading Criteria Changes New Pathway 2012

1. Grading Criteria Changes New Pathway 2012 Robert Brown & Yvonne D’Souza SMDESP – June 2012

2. New Pathway diagram

3. How will it effect SMDESP? • Removal of 6/12 Re-screen • Discontinuation of R1.5 & M0.5 • OPDR – Virtual Surveillance Clinic • Clarity in grading criteria

4. Retinopathy Grading Criteria

5. Grading changes in the new pathway • Defining the R2 pre-proliferative level • Defining groups of exudates • Introducing a stable treated R3 grade • Simplifying image quality into adequate and inadequate (no longer a ‘good’category)

6. The R2 Pre-proliferative level • Venous beading • Venous reduplication • Multiple blot haemorrhages • IRMA • New definition

7. OPDR Pathway • Pregnant women • Patients who require increased level of surveillance • Patients discharged from HES • More frequent photography + OCT

10. Referable

13. Referable

16. Referable

19. Not referable

22. Not referable

25. Not referable

26. IRMA – Intraretinal microvascular abnormalities • The amount of haemorrhage present in the following image sets does not warrant a referral. • However, a careful search for IRMA should be made when the amount of haemorrhages is equal to that shown in the images. • Patients with IRMA that are definitely seen should be referred into the Hospital Eye Service.

35. Grading IRMA • Only IRMA that are definitely seen should be referred • Once an IRMA is found, one should always return to the colour image. IRMA is considered present if the IRMA can still be seen on the colour image as well as on the red free. • If an IRMA can only be seen on a red free image and not on the colour image a referral should not be made (return to annual screening).

36. Localised patch of IRMA • If there is a localised patch of possible IRMA in one area of the retina with very little other signs of diabetic retinopathy, one needs to consider whether a small branch vein occlusion may have occurred in this area in the past and that these might be small collaterals. If it is judged that small collaterals are present from an old small vein occlusion instead of IRMA, this would not warrant a referral.

37. R3 Proliferative Grading Criteria

38. R3 (Proliferative Diabetic Retinopathy) R3 will be split into • R3a (Active Proliferative Retinopathy) and • R3s (Stable Treated Proliferative Retinopathy)

39. R3s (Proliferative Diabetic Retinopathy The Definition of R3s (Stable) will be • Evidence of Peripheral Retinal Laser Treatment • AND • Stable retina from photograph taken at or shortly after discharge from the HES

40. R3s • Guidance to the discharging ophthalmologist must make it clear that the English NHS Diabetic Eye Screening Programme only operates an annual screening programme and that they should only discharge patients who they assess are at sufficiently low risk to receive 12 monthly photographic screening. • Assuming that the screening programme has an OPDR pathway it is recommended that stable treated retinopathy is kept in the OPDR pathway.

41. R3s • On discharge, the hospital must either place a discharge set of images on the Screening Service software, supply a set of images electronically for the service to import or arrange for a set of discharge images to be taken by the Screening Service within 3 months.

42. Maculopathy Grading Criteria

43. Revised definition of a Group of Exudates • A group of exudates is an area of exudates that is greater than or equal to half the disc areaandthis area (of greater than or equal half the disc area) is all within the macular area

45. Referable

47. Referable

49. Not Referable