Elsevier

Ophthalmology

Volume 110, Issue 9, September 2003, Pages 1677-1682
Ophthalmology

Regular article
Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales

Presented at the American Academy of Ophthalmology Annual Meeting: International Clinical Classification of Diabetic Retinopathy, Orlando, Florida, October 2002.
https://doi.org/10.1016/S0161-6420(03)00475-5Get rights and content

Abstract

Purpose

To develop consensus regarding clinical disease severity classification systems for diabetic retinopathy and diabetic macular edema that can be used around the world, and to improve communication and coordination of care among physicians who care for patients with diabetes.

Design

Report regarding the development of clinical diabetic retinopathy disease severity scales.

Participants

A group of 31 individuals from 16 countries, representing comprehensive ophthalmology, retina subspecialties, endocrinology, and epidemiology.

Methods

An initial clinical classification system, based on the Early Treatment Diabetic Retinopathy Study and the Wisconsin Epidemiologic Study of Diabetic Retinopathy publications, was circulated to the group in advance of a workshop. Each member reviewed this using e-mail, and a modified Delphi system was used to stratify responses. At a later workshop, separate systems for diabetic retinopathy and macular edema were developed. These were then reevaluated by group members, and the modified Delphi system was again used to measure degrees of agreement.

Main outcome measures

Consensus regarding specific classification systems was achieved.

Results

A five-stage disease severity classification for diabetic retinopathy includes three stages of low risk, a fourth stage of severe nonproliferative retinopathy, and a fifth stage of proliferative retinopathy. Diabetic macular edema is classified as apparently present or apparently absent. If training and equipment allow the screener to make a valid decision, macular edema is further categorized as a function of its distance from the central macula.

Conclusions

There seems to be a genuine need for consistent international clinical classification systems for diabetic retinopathy and diabetic macular edema that are supported with solid evidence. The proposed clinical classification systems provide a means of appropriately categorizing diabetic retinopathy and macular edema. It is hoped that these systems will be valuable in improving both screening of individuals with diabetes and communication and discussion among individuals caring for these patients.

Section snippets

Material and methods

At the time of the initiation of this project, it was agreed that the clinical disease severity scale should be evidence based, using data from important clinical studies such as the ETDRS and the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR)8, 9 The severity scale was intended to be primarily aimed at comprehensive ophthalmologists and primary care physicians, because these individuals see most patients with diabetes. Retinal specialists were considered to be familiar with the

Results

The results of the ratings for each of the stages (and some alternative definitions based on alternative views) after all deliberations are presented in Table 1. Regarding diabetic retinopathy, there was 100% agreement regarding the desirability of a level for “no retinopathy,” and there was significant disagreement for including “no apparent retinopathy” and “minimal nonproliferative retinopathy” in a single significant level (Table 1). There was 100% agreement regarding a level for

Discussion

The need to provide a framework for improved communications and transfer of information among the primary care physician, endocrinologist, ophthalmologist, and other eye care providers was a major impetus to develop simplified clinical disease severity scales that could be used internationally. This international clinical classification system is based on an evidence-based approach, particularly the findings of the ETDRS and the WESDR.2, 9 These two studies have provided an understanding of the

References (11)

  • Photocoagulation treatment of proliferative diabetic retinopathythe second report of diabetic retinopathy study findings

    Ophthalmology

    (1978)
  • Early photocoagulation for diabetic retinopathy. ETDRS report number 9

    Ophthalmology

    (1991)
  • R. Klein

    Barriers to prevention of vision loss caused by diabetic retinopathy

    Arch Ophthalmol

    (1997)
  • A modification of the Airlie House classification of diabetic retinopathy. Report 7

    Invest Ophthalmol Vis Sci

    (1981)
  • T.J. Verdaguer

    Screening para retinopatia diabetica en Latino America. Resultados

    Rev Soc Brasil Retina Vitreo

    (2001)
There are more references available in the full text version of this article.

Cited by (0)

Manuscript no. 220905.

Supported by Eli Lilly Company, Indianapolis, Indiana.

There are no conflicts of interest related to the manuscript on the part of authors.

Reprint requests to Flora Lum, MD, American Academy of Ophthalmology, 655 Beach Street, P.O. Box 7424, San Francisco, CA 94120-7424.

View full text