最新美国眼科协会临床指南：糖尿病视网膜病变

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美国眼科学会临床实践指南系列丛书：糖尿病视网膜病变

DiabeticRetinopathyPrepared by the AmericanAcademy of OphthalmologyRetina PanelRetina Panel MembersEmily Y. Chew, MD, Chair, Macula Society and Retina Society Representative William E. Benson, MDH. Culver Boldt, MDTom S. Chang, MDLouis A. Lobes, Jr., MDJoan W. Miller, MDTimothy G. Murray, MD, American Societyof Retina Specialists Representative Marco A. Zarbin, MD, PhDLeslie Hyman, PhD, Methodologist Preferred Practice Patterns Committee MembersJoseph Caprioli, MD, ChairJ. Bronwyn Bateman, MDEmily Y. Chew, MDDouglas E. Gaasterland, MDSid Mandelbaum, MDSamuel Masket, MDAlice Y. Matoba, MDDonald S. Fong, MD, MPHAcademy StaffNancy Collins, RN, MPHFlora C. Lum, MDMario ReynosoMedical Editor: Jeff Van BuerenDesign: Socorro Soberano Reviewed by: CouncilApproved by: Board of TrusteesSeptember2003 Copyright © 2003American Academy of Ophthalmology ®All rights reserved As a service to its members and the public, the American Academy of Ophthalmology has developed a series of guidelines called Preferred Practice Patterns™ that identify characteristics and components of quality eye care.The Preferred Practice Patterns are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence.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. The 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.Preferred Practice Patterns 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.Innovation in medicine is essential to assure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients’ needs are the foremost consideration.All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current, each is valid for 5 years from the “approved by” date unless superseded by a revision.Financial Disclosures:No proprietary interests were disclosed by members of the Preferred Practice Patterns Retina Panel for the past 3 years up to and including June 2003 for product, investment, or consulting services regarding the equipment, process, or products presented or competing equipment, process, or products presented.TABLE OF CONTENTSINTRODUCTION (2)ORIENTATION (3)Entity (3)Disease Definition (3)Patient Population (3)Activity (3)Purpose (3)Goals (3)BACKGROUND (4)Epidemiology (4)Risk Factors (4)Natural History (4)PREVENTION AND EARLY DETECTION (6)CARE PROCESS (8)Patient Outcome Criteria (8)Diagnosis (8)History (9)Examination (9)Examination Schedule (9)Type 1 (Diabetes Onset Usually between Ages 0 and 29 Years) (9)Type 2 (Diabetes Onset Usually at Age 30 Years or Older) (9)Diabetes Associated with Pregnancy (10)Ancillary Tests (10)Color Fundus Photography (10)Fluorescein Angiography (10)Ultrasonography (Echography) (11)Optical Coherence Tomography (11)Treatment (11)Normal or Minimal NPDR (12)Mild to Moderate NPDR without Macular Edema (13)Mild to Moderate NPDR with Clinically Significant Macular Edema (13)Severe and Very Severe NPDR and Non-High-Risk PDR (14)High-Risk PDR (15)High-Risk PDR Not Amenable to Photocoagulation (15)Other Treatments (16)Side Effects and Complications of Treatment (16)Focal Photocoagulation for Diabetic Macular Edema (16)Scatter Photocoagulation for Severe NPDR or PDR (16)Vitrectomy (16)Follow-up (16)History (16)Provider (17)Counseling/Referral (17)APPENDIX 1. SUMMARY OF MAJOR RECOMMENDATIONS FOR CARE (18)APPENDIX 2. TREATMENT TRIAL RESULTS (20)APPENDIX 3. GLYCEMIC CONTROL (22)APPENDIX 4. COST-BENEFIT ANALYSES (23)GLOSSARY (24)RELATED ACADEMY MATERIALS (27)REFERENCES (28)INTRODUCTIONThe Preferred Practice Patterns (PPP) 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.In the process of revising this document, a detailed literature search of articles in the Englishlanguage was conducted on the subject of diabetic retinopathy for the years 1997 to 2002. Theresults were reviewed by the Retina Panel and used to prepare the recommendations, which they rated in two ways. 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 importantLevel B, defined as moderately importantLevel C, defined as relevant but not criticalThe 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 intothree 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 randomizationWell-designed cohort or case-control analytic studies, preferably from more than one centerMultiple-time series with or without the interventionLevel III includes evidence obtained from one of the following:Descriptive studiesCase reportsReports of expert committees/organization s (e.g., PPP panel consensus with peer review)The evidence cited is that which supports the value of the recommendation as something thatshould be performed to improve the quality of care. The panel believes that it is important to make available the strength of the evidence underlying the recommendation. In this way, readers canappreciate the degree of importance the committee attached to each recommendation and they can understand what type of evidence supports the recommendation.The ratings of importance and the ratings of strength of evidence are given in bracketedsuperscripts after each recommendation. For instance, “[A:II]” indicates a recommendation with high importance to clinical care [A], supported by sufficiently rigorous published evidence,though not by a randomized controlled trial [II].The sections entitled Orientation and Background do not include recommendations; rather they are designed to educate and provide summary background information and rationale for therecommendations that are presented in the Care Process section. A summary of the majorrecommendations for care is included in Appendix 1.ORIENTATIONENTITYDiabetic retinopathy (ICD-9 #362.01 and 362.02)DISEASE DEFINITIONDiabetic retinopathy is a disorder of the retinal vasculature that eventually develops to somedegree in nearly all patients with long-standing diabetes mellitus. The earliest visible clinicalmanifestations of retinopathy include microaneurysms and hemorrhages. Vascular alterations can progress to retinal capillary nonperfusion, resulting in a clinical picture characterized by increased numbers of hemorrhages, cotton-wool spots, and intraretinal microvascular abnormalities (IRMA).Finally, increasing nonperfusion can lead to closure of retinal vessels and pathologic proliferation of retinal vessels, characterized by neovascularization on the disc or elsewhere. Increasedvasopermeability results in retinal thickening (edema) during the course of diabetic retinopathy.Visual loss results mainly from macular edema, macular capillary nonperfusion, vitreoushemorrhage, and distortion or traction detachment of the retina.A description of the fundus findings in various stages of diabetic retinopathy is located in theNatural History section. Important terms are defined in the Glossary.PATIENT POPULATIONThe patient population includes all patients with diabetes mellitus.ACTIVITYEvaluation and management of diabetes-related retinal disease.PURPOSEThe primary purpose of evaluating and managing diabetic retinopathy is to prevent, retard, orreverse visual loss, thereby maintaining or improving vision-related quality of life.GOALSIdentify patients at risk for developing diabetic retinopathy.Encourage involvement of the patient and primary care physician in the management of the patient’s systemic disorder, with specific attention to control of blood sugar (hemoglobin A1c),serum lipids, and blood pressure.Encourage and provide lifelong evaluation of retinopathy progression.Treat patients at risk for visual loss from diabetic retinopathy.Minimize the side effects of treatment that might adversely affect the patient’s vision and/or vision-related quality of life.Provide visual rehabilitation for patients with visual loss from the disease or refer for visual rehabilitation.BACKGROUNDEPIDEMIOLOGYDiabetic retinopathy is the leading cause of new cases of legal blindness among working-ageAmericans. An estimated 29 million Americans age 20 years or older have either diagnoseddiabetes mellitus, undiagnosed diabetes, or impaired fasting blood glucose levels; about one third are not aware that they have the disease.1For the purposes of this PPP, two forms of diabetes mellitus are recognized. Type 1, previously called juvenile-onset or insulin-dependent diabetes, is characterized by beta-cell destruction and usually leads to absolute insulin deficiency. Type 2, previously called adult-onset or noninsulin-dependent diabetes, is characterized by insulin resistance with an insulin secretory defect thatleads to relative insulin deficiency.2 Many patients with type 2 diabetes take insulin.Between 90% and 95% of patients with diabetes have type 2 diabetes. Because of the disproportionately large number of patients with type 2 diabetes, this group comprises a substantial proportion of patients with visual impairment secondary to diabetic retinopathy, even though type 1 diabetes isassociated with more frequent and more severe ocular complications.3 The increased frequency of childhood obesity may result in an increased frequency of type 2 diabetes in the pediatric agegroup.4RISK FACTORSDuration of diabetes is a major risk factor associated with the development of diabetic retinopathy.After 5 years, approximately 25% of type 1 patients have retinopathy. After 10 years, almost 60% have retinopathy, and after 15 years, 80% have retinopathy. Proliferative diabetic retinopathy, the most vision-threatening form of the disease, is present in approximately 25% of type 1 patientswith 15 years’ duration of the disease.5Of type 2 patients who have a known duration of diabetes of less than 5 years, 40% of thosepatients taking insulin and 24% of those not taking insulin have retinopathy. These rates increase to 84% and 53%, respectively, when the duration of diabetes has been documented for up to 19 years. Proliferative retinopathy develops in 2% of type 2 patients who have diabetes for less than 5 years and in 25% of patients who have diabetes for 25 years or more.6The severity of hyperglycemia is the key alterable risk factor associated with the development of diabetic retinopathy. Support for this association is found in results of both clinical trials andepidemiologic studies.7-9 There is general agreement that duration of diabetes and severity ofhyperglycemia are the major risk factors for developing retinopathy. After retinopathy is present,duration of diabetes appears to be a less important factor than hyperglycemia for progression from earlier to later stages of retinopathy.9 Intensive management of hypertension has been demonstrated to slowretinopathy progression.10, 11 There is less agreement between studies concerning the importance of other factors such as age, type of diabetes, clotting factors, renal disease, and use of angiotensin-convertingenzyme inhibitors.9, 12-14 Many of these factors are associated with the significant cardiovascularmorbidity and mortality and other complications associated with diabetes. Thus, it is reasonable toencourage patients with diabetes to be as compliant as possible with therapy of all medical aspects oftheir disease.NATURAL HISTORYDiabetic retinopathy progresses in an orderly fashion from minimal changes to more severe stages if there is no intervention. It is important to recognize the stages in which treatment may bebeneficial. Several decades of clinical research have provided excellent data on the natural course of the disease and on treatment strategies that are 90% effective in preventing the occurrence of severe vision loss. These studies include five major clinical trials: the Diabetes Control andComplications Trial (DCCT),8, 15, 16 the Diabetic Retinopathy Study (DRS),17-19 the EarlyTreatment Diabetic Retinopathy Study (ETDRS),20-31 the Diabetic Retinopathy Vitrectomy Study (DRVS),32-35 and the United Kingdom Prospective Diabetes Study (UKPDS).10, 36, 37The outcomesof these trials are solid foundations underlying the Preferred Practice Pattern for treating diabeticretinopathy. The results of these studies are presented in Appendices 2 and 3.Diabetic retinopathy in its earliest stages is called nonproliferative diabetic retinopathy (NPDR)and is characterized by retinal vascular abnormalities including microaneurysms, intraretinalhemorrhages, and cotton-wool spots. Increased retinal vascular permeability that occurs at this orlater stages of retinopathy may result in retinal thickening (edema) and lipid deposits (hardexudates). Clinically significant macular edema (CSME)is a term commonly used for retinalthickening and/or adjacent hard exudates that either involve the center of the macula or threaten tospread into it. Patients with CSME should be considered for focal laser photocoagulation,particularly if the center of the macula is already involved or if retinal thickening/adjacent hardexudates are very close to it(see Care Process).As diabetic retinopathy progresses, there is a gradual closure of retinal vessels, which results inimpaired perfusion and retinal ischemia. Signs of increasing ischemia include venousabnormalities (beading, loops, etc.), IRMA, and more severe and extensive vascular leakagecharacterized by increasing retinal hemorrhages and exudation.When these signs progress beyondcertain defined thresholds, severe nonproliferative diabetic retinopathy(severe NPDR) isdiagnosed (see Glossary for definition).Patients with this degree of retinopathy should beconsidered for possible treatment with scatter laser photocoagulation (see Care Process).The more advanced stage, proliferative diabetic retinopathy (PDR), is characterized by the onsetof neovascularization on the inner surface of the retina induced by the retinal ischemia. Newvessels at the optic disc (NVD) and new vessels elsewhere in the retina (NVE) are prone to bleed,resulting in vitreous hemorrhage. These new vessels may undergo fibrosis and contraction; thisand other fibrous proliferation may result in epiretinal membrane formation, vitreoretinal tractionbands, retinal tears, and traction or rhegmatogenous retinal detachments. When new vessels areaccompanied by vitreous hemorrhage, or when new vessels at the optic disc occupy greater than orequal to about 1/4 to 1/3 disc area, even in the absence of vitreous hemorrhage, PDR is said to bein the high-risk stage (high-risk PDR; see Glossary for definition).Neovascular glaucoma canresult from new vessels growing on the iris and anterior chamber angle structures. Patients withneovascular glaucoma or high-risk PDR should receive prompt scatter photocoagulation(see CareProcess).In an attempt to improve communication worldwide between ophthalmologists and primary carephysicians caring for patients with diabetes, an international clinical disease severity scale wasrecently developed for diabetic retinopathy and macular edema (Tables 1 and 2).38 This scale isbased on the ETDRS classification of diabetic retinopathy and on the data collected in clinicaltrials and epidemiologic studies of diabetic retinopathy. However, the scheme remains to bevalidated.TABLE 1International Clinical Diabetic Retinopathy Disease Severity ScaleProposed Disease Severity Level Findings Observable upon Dilated OphthalmoscopyNo apparent retinopathy No abnormalitiesMild nonproliferative diabetic retinopathy Microaneurysms onlyModerate nonproliferative diabetic retinopathy More than just microaneurysms but less than severe NPDRSevere nonproliferative diabetic retinopathy♦ ♦ ♦ More than 20 intraretinal hemorrhages in each of four quadrants Definite venous beading in two or more quadrants Prominent IRMA in one or more quadrantsAnd no signs of proliferative retinopathy Proliferative diabetic retinopathy One or both of the following:♦ ♦ Neovascularization Vitreous/preretinal hemorrhageIRMA = intraretinal microvascular abnormalities; NPDR = nonproliferative diabetic retinopathyTABLE 2 International Clinical Diabetic Macular Edema Disease Severity ScaleProposed Disease Severity Level Findings Observable upon Dilated OphthalmoscopyDiabetic macular edema apparently absent Diabetic macular edema apparently present No apparent retinal thickening or hard exudates in posterior pole Some apparent retinal thickening or hard exudates in posterior pole If diabetic macular edema is present, it can be categorized as follows:Proposed Disease Severity LevelFindings Observable upon Dilated Ophthalmoscopy* Mild diabetic macular edema: Some retinal thickening or hard exudates in posterior pole butdistant from the center of the maculaModerate diabetic macular edema: Retinal thickening or hard exudates approaching the center ofthe macula but not involving the centerDiabetic macular edema present ♦Severe diabetic macular edema: Retinal thickening or hard exudates involving the center of themacula ♦ ♦ * Hard exudates are a sign of current or previous macular edema. Diabetic macular edema is defined as retinal thickening; this requires a three-dimensional assessment that is best performed by dilated examination using slit-lamp biomicroscopy and/or stereo fundus photography.PREVENTION AND EARLY DETECTIONAlthough a healthy lifestyle with exercise and weight control may decrease the risk of developing diabetes in some patients,39, 40 in many cases diabetes cannot be prevented. In contrast, in many cases the blinding complications of diabetes mellitus can be prevented or moderated. Treatment can yield significant cost savings compared with the direct costs for those disabled by vision loss (see Appendix 4). Analyses from two clinical trials show that the treatment for diabeticretinopathy may be 90% effective in preventing severe vision loss (visual acuity less than 5/200) with current treatment strategies.41 Although effective treatment is available, the number of patients with diabetes referred by their primary care physicians for ophthalmic care is far below the guidelines of the American Diabetes Association and the American Academy ofOphthalmology.42 In a community-based intervention trial, at enrollment 35% of participants did not follow the vision care guidelines; two thirds of this group reported no eye examination in the year prior to enrollment and one third had an undilated examination.43In one epidemiologic study of over 2000 diabetes patients, 11% of type 1 patients and 7% of type 2 patients with high-risk PDR had not been seen by an ophthalmologist within 2 years.44 In this study, 46% of eyes with high-risk PDR had not received photocoagulation surgery.44 According to the National Committee for Quality Assurance’s Health Plan Employers Data Information Set 3.0 System, the average rate of annual eye examinations for patients with diabetes was 45% across participating health plans in 2000. Among prepaid health plan enrollees, 77% of patients with diabetes received an eye examination over a 3-year study period.45 A longitudinal analysis of Medicare claims data for beneficiaries age 65 years or older found that 50% to 60% had annual eye examinations in a 15-month period.46 Ophthalmologists, physicians who care for patients with diabetes, and patients themselves need to be educated about indications for referral.Recommended intervals for eye examinations for patients with diabetes are given in Table 3.TABLE 3Recommended Eye Examination Schedule for Patients with Diabetes Mellitus Diabetes Type Recommended Time ofFirst ExaminationRecommended Follow-up* Type 1 5 years after onset5[A:II] Yearly5 [A:II]Type 2 At time of diagnosis6 [A:II] Yearly6 [A:II]Prior to pregnancy (type 1 or type 2) Prior to conception or early in the firsttrimester47-49 [A:I]No retinopathy to mild or moderate NPDR: every 3–12 months47-49 [A:I]Severe NPDR or worse: every 1–3 months47-49 [A:I]* Abnormal findings may dictate more frequent follow-up examinations.NPDR = nonproliferative diabetic retinopathyThe primary prevention and screening process for diabetic retinopathy varies according to the age of onset of the disease. Several forms of retinal screening with standard fundus photography ordigital imaging, with and without dilation, are being investigated as a means of detectingretinopathy early, and they warrant further evaluation.50Some studies have shown that screening to identify sight-threatening retinopathy with photography is more sensitive than clinicalexamination with ophthalmoscopy.51-54 It is not clear whether the new digital photographytechniques (e.g., single-field, 45-degree photo) are as sensitive and specific as traditional standard seven-field stereoscopic 30-degree fundus photographs for determining the level of diabeticretinopathy.55 Most digital nonmydriatic cameras lack stereoscopic capability, which is useful for identifying subtle neovascularization and macular edema.42 However, digital nonmydriaticcameras that operate stereoscopically have been validated against fundus photography and mayeventually prove to be useful tools in future studies. At this time it is not clear that photographic screening programs achieve a greater reduction in vision loss compared with routine community care in areas where access to ophthalmologists is straightforward.42 Of course, such screeningprograms have great value in circumstances in which access to ophthalmic care is limited.53, 55 At this time, these technologies are not considered a replacement for a comprehensive eye evaluation by an ophthalmologist experienced in managing diabetic retinopathy.Ophthalmologists can play an important role in diabetic care apart from treating eye disease.Patients can be counseled about the importance of blood glucose and blood pressure control, for example, at the time of the eye examination.The results of the DCCT showed that the development and progression of diabetic retinopathy in patients with type 1 diabetes can be delayed if glucose concentrations are maintained in the near-normal range (see Appendix 3).15 After 3 years of intensive treatment to reduce glucose levels, the DCCT showed that among patients without retinopathy, the development of any retinopathy was reduced by 75% but not prevented completely over the 9-year course of the study. The benefit of strict glucose control also was evident in patients with existing retinopathy (50% reduction in the rate of progression of retinopathy compared with controls). At the 6- and 12-month visits, a small adverse effect of intensive treatment on retinopathy progression was seen, similar to that described in other trials of intensive glucose control. This small adverse effect was a transient earlyworsening of the retinopathy in the intensive treatment group within the first 2 years of treatment, with no effect on visual acuity. Beyond 3.5 years of follow-up, the risk of progression was fivetimes lower with intensive insulin treatment than with conventional treatment.Evidence about the effects of controlling hyperglycemia in type 2 patients comes fromobservational data as well as randomized clinical trials. Definitive results were seen in theUKPDS,37, 56 a randomized, controlled clinical trial of blood glucose control in 3867 patients with newly diagnosed type 2 diabetes. Intensive blood glucose control by either the sulfonylureas orinsulin decreased the risk of microvascular complications but not the risk of macrovasculardisease. There were no adverse effects of the individual drugs on the cardiovascular outcome. In this study, there was a 29% reduction in the need for retinal photocoagulation surgery in the group with intensive glucose therapy compared with those with conventional treatment (relative risk,0.71; 95% confidence interval, 0.53–0.96; P=0.003).Also in the UKPDS, 1148 patients with both diabetes and hypertension were randomly assigned to antihypertensive treatment.10 Additional analyses from this nested trial of antihypertensivemedications (captopril, an angiotensin-converting enzyme inhibitor, or atenolol, a beta blocker) showed that tight blood pressure control achieved a clinically important reduction in the risk of deaths related to diabetes and in the risk of progression of diabetic retinopathy. There was a 34% reduction in the risk of progression of retinopathy from baseline by two or more steps by a median of 7.5 years (P=0.004) and a 47% reduced risk of decreased vision by three lines on the ETDRS chart (P=0.004). There was no difference in the progression of retinopathy or the final visualacuity in those patients treated with an angiotensin-converting enzyme inhibitor compared with those treated with a beta blocker.It is important to educate all patients with diabetes about the disease and to stress the value ofmaintaining blood glucose (as monitored by hemoglobin A1c) as near normal as is safely possible.The results of the DCCT showed that lowering blood glucose reduces other end-organcomplications as well, including nephropathy and neuropathy (see Appendix 3). The results of the UKPDS demonstrate the value of controlling blood glucose and blood pressure in all patients with type 2 diabetes.Medical treatment such as aspirin therapy has been evaluated for the prevention and retardation of diabetic retinopathy. The ETDRS found no evidence that aspirin therapy retards or accelerates the progression of diabetic retinopathy22 or that it causes more severe or more long-lasting vitreous hemorrhages in patients with PDR.57CARE PROCESSThe care process for diabetic retinopathy includes a medical history, an ophthalmic examination, and vigilant follow-up. Early detection of retinopathy depends on educating patients with diabetes as well as their families, friends, and eye care providers about the importance of regular eyeexamination even though the patient may be asymptomatic. Patients with diabetes mellitus without diabetic retinopathy should be encouraged to have annual dilated eye examinations to detect the onset of diabetic retinopathy.[A:III] Patients should also be informed that effective treatment fordiabetic retinopathy depends on timely intervention, despite good vision and no ocularsymptoms.[A:III] (The recommended timing of the first ophthalmic exam and subsequent follow-up exams for patients with diabetes is given in the section Examination Schedule and in Table 3.)Patient education about the importance of maintaining near-normal glucose levels and near-normal blood pressure and lowering serum lipid levels is an important aspect of the care process.[A:III]Many patients are still not aware of the importance of maintaining good glucose control andmonitoring serum glycosylated hemoglobin levels. Aspirin may be used without concern forworsening diabetic retinopathy by patients with diabetes who require aspirin for other medicalindications and have no contraindications.22, 57 [A:I]PATIENT OUTCOME CRITERIAPatient outcome criteria include the following:Improvement or stabilization of visual functionImprovement or stabilization of vision-related quality of lifeCoordination of care management to achieve optimal glycemic controlDIAGNOSISThe initial examination for a patient with diabetes mellitus includes all features of thecomprehensive adult medical eye evaluation,58 with particular attention to those aspects relevant to diabetic retinopathy.。

糖尿病视网膜病变诊治规范美国眼科学会临床指南解读

（3）开展公众健康教育，提高人民群众的健康意识和自我保健能力，使其能够及时发现并重视DR等慢性疾病的症状。
四、结论
四、结论
DR是一种严重的眼部并发症，如不及时治疗会导致视力下降甚至失明。SCL作为美国眼科学会制定的DR诊治规范，具有极高的科学性和规范性，为全球的DR诊治提供了重要的参考。在我国，虽然DR的发病率逐年上升，但对其诊治仍存在诸多问题和挑战。我们应该积极应对，加强医生培训，提高医疗技术水平，加强公众健康教育，以期能够更好地预防和控制DR的发病，提高人民群众的生活质量。
二、SCL的制定原则和主要内容
（4）激光治疗：用激光束凝固视网膜病变区域，以减轻视网膜水肿、减少新生血管的产生。
二、SCL的制定原则和主要内容
（5）手术治疗：对于严重的DR患者，可能需要手术治疗，如玻璃体切割术等。
二、SCL的制定原则和主要内容
3.药物选择：SCL提出了一些可用于DR治疗的药物，包括抗血管内皮生长因子（VEGF）药物如贝伐单抗和雷珠单抗等，以及一些抗炎药物如地塞米松等。同时，也强调了根据病情选择合适药物的重要性。
糖尿病视网膜病变诊治规范美国眼科学会临床指南解读
目录
01 一、DR的基本概念、流行情况和危害
03 四、结论
02
二、SCL的制定原则和主要内容
内容摘要
糖尿病视网膜病变（DR）是糖尿病患者最常见的眼部并发症之一，也是导致视力损害和失明的主要原因之一。为了规范DR的诊治，美国眼科学会（AAO）制定了相关的诊治规范（SCL），以期提高医生的诊治水平，保障患者的视觉健康。本次演示将介绍DR的基本概念、流行情况和危害，并解读SCL的实际应用价值，为我国的DR诊治提供参考。
谢谢观看

糖尿病性视网膜病变

缺血型黄斑病变
黄斑部出现NP，且至少一处距黄斑中心凹小于1DD，黄斑拱部扩张的毛细血管及单个或成簇的微血管瘤；晚期渗漏仅占黄斑部的局部区域（<2个象限）。
局限性渗漏
黄斑弥漫水肿型
荧光素渗漏来自黄斑部弥漫性扩张的毛细血管；造影晚期渗漏占据黄斑部全部或大部分区域（≥2个象限）。
在NPDR ，糖尿病黄斑病变对视力有明显的损害。从治疗角度来看，根据FFA的分型结果，可针对不同类型的黄斑病变，采用相应的方法治疗。尤其对NPDR，若合并有糖尿病黄斑水肿，结合视力情况，及时行光凝治疗，可改善和保存视力。
糖尿病黄斑病变与PDR的关系
黄斑部特殊的生理结构
黄斑部脉络膜胶体渗透压高于视网膜其他部位；
老年人视网膜内屏障功能较弱视网膜色素上皮层水泵作用减弱常发生视网膜小血管、后极部脉络膜血管硬化，黄斑血液循环欠佳。
多伴有其他全身疾病
60岁以上的糖尿病病人多存在显著
。的脂质代谢紊乱
五、治疗
1.西医治疗原发病的治疗：严格控制血糖是减低DRP和
DME的危险和进展的最基本治疗措
（饮食治疗：控制总热量，提供足够的营养素；药物治疗：磺脲类、双胍类、葡萄糖苷酶抑制剂、
（一）西医认识
1.病因
未完全阐明。
高血糖——发病基础
2.病理
早期主要病理改变在Cap：周细胞减少、基底膜增厚， Cap管腔减小、 Cap内皮屏障失代偿。
Retinal capillary
二、病因病理
3. 发病的相关因素与病程（病程>20年，1型99%、2型>60
％）、血糖、血脂、血压、胰岛素水平、眼压、糖尿病肾病、贫血、妊娠等有关

中医眼科临床诊疗指南——糖尿病视网膜病变

中医眼科临床诊疗指南——糖尿病视网膜病变1.范围本《指南》规定了糖尿病视网膜病变的诊断、辨证和治疗。

本《指南》适用于糖尿病视网膜病变的诊断和治疗。

2.术语和定义下列术语和定义适用于本指南。

糖尿病视网膜病变（diabetic retinopathy，DR）是糖尿病导致的视网膜微血管损害所引起一系列典型病变，是一种影响视力甚至致盲的慢性进行性疾病。

“消渴内障”，为“消渴目病”之一，属“视瞻昏渺”、“云雾移睛”、“暴盲”及“血灌瞳神”等内障眼病范畴。

3.诊断3.1诊断要点3.1.1.症状早期眼部多无自觉症状，病久可有不同程度视力减退，眼前黑影飞舞，或视物变形，甚至失明。

3.1.2.体征DR的眼底表现包括微动脉瘤、出血、硬性渗出、棉絮斑、静脉串珠状、IRMA、黄斑水肿、新生血管、视网膜前出血及玻璃体积血等。

3.1.3.并发症DR的并发症有牵拉性视网膜脱离、虹膜新生血管及新生血管性青光眼等。

（1）牵拉性视网膜脱离视网膜增殖膜及新生血管膜收缩，是引发牵拉性视网膜脱离的主要原因。

（2）虹膜新生血管及新生血管性青光眼DR广泛的视网膜缺血，诱生血管生长因子，刺激虹膜及房角产生新生血管。

虹膜新生血管表现为虹膜表面出现的细小弯曲、不规则血管，多见于瞳孔缘，可向周边发展；房角新生血管阻塞或牵拉小梁网，或出血，影响房水引流，导致眼压升高，形成新生血管性青光眼。

3.1.4.眼科检查（1）视力：裸眼视力（远近视力）和矫正视力。

（2）眼压（3）裂隙灯显微镜检查（4）眼底检查：散瞳后进行眼底检查。

（5）彩色眼底照相彩色眼底照相发现DR的重复性比其他检查要好，对于记录DR的明显进展和治疗的反应方面是有其价值的。

但在发现黄斑水肿的视网膜增厚及细微的新生血管方面，FFA和OCT更具有优越性。

（6）荧光素眼底血管造影（FFA）检眼镜下未见DR眼底表现的患者，FFA检查可出现异常荧光，如微血管瘤样强荧光、毛细血管扩张或渗漏、视网膜血管无灌注区、新生血管及黄斑囊样水肿等。

《糖尿病视网膜病变》PPT课件

辅助检查
根据需要，进行OCT、FFA等辅助检查，进一步确诊病变程度和范围。
治疗建议
根据病情严重程度和治疗指南，向患者提供个性化的治疗建议和生活方式指导。
CHAPTER
04
糖尿病视网膜病变的治疗
药物治疗
抗血管内皮生长因子药物
如贝伐单抗、雷珠单抗等，可抑制血管内皮生长因子，减少血管渗漏和新生血管形成。
病理生理
糖尿病视网膜病变的病理生理过程包括毛细血管通透性增加、血液瘀滞、血流变异常、缺氧等，这些因素共同作用，导致视网膜微血管病变。
流行病学与发病率
流行病学
糖尿病视网膜病变是糖尿病最常见的微血管并发症之一，在糖尿病患者中发病率较高，且随年龄增长而增加。
发病率
根据不同研究数据，糖尿病视网膜病变的发病率在糖尿病患者中约为30%-50% ，且随着病程延长和血糖控制不佳，发病率逐渐升高。
通过观察Amsler网格的扭曲、缺失等现象，初步判断视网膜病变程度。
评估标准
国际临床分级标准（DRS）
01
根据眼底病变程度，将糖尿病视网膜病变分为五个等级，用于
评估病情严重程度和制定治疗方案。
美国糖尿病协会标准（ADA）
02
根据视网膜病变程度和危险因素，将糖尿病视网膜病变分为三
个阶段，用于指导治疗和预防措施。
案例二：中期糖尿病视网膜病变的激光治疗
总结词
激光治疗是中期病变的有效手段，可减少病变进展的风险。
详细描述
在中期糖尿病视网膜病变中，激光治疗成为主要的治疗方法。通过激光凝固视网膜病变区域，可以减少血管渗漏和防止微血管瘤形成，从而控制病变进展。
案例三：晚期糖尿病视网膜病变的手术治疗
总结词

眼科糖尿病性视网膜病变诊疗技术

眼科糖尿病性视网膜病变诊疗技术糖尿病(DM)是一种由于胰岛素绝对或相对分泌不足所致的以糖代谢紊乱为主的常见疾病。

临床上主要分为两型，I型，又称为胰岛素依赖型(IDDM)；II型，也称为非胰岛素依赖型(NIDDM)o∏型远较I型多见。

糖尿病可引起全身许多组织、器官的广泛损害，在眼部可引起多种疾病，如视网膜病变、白内障、青光眼和眼内、外肌麻痹等，而糖尿病视网膜病变(diabeticretinopathy,DR)则是其中最严重的微血管并发症之一。

一、流行病学在美国，糖尿病视网膜病变是工作年龄人群首位致盲性眼病。

近年来随着人们生活水平的提高和饮食结构的改变，我国糖尿病发病率也逐年增加，据统计，20世纪80年代初为0.67%、90年代中期则增长为2.5%。

因此DR也成为我国人群重要的致盲性眼病之一。

胰岛素依赖型的糖尿病患者，约10%起病后5〜9年左右便可发生视网膜病变，15年后约50%的人发生，25年后有约80%〜90%的人出现视网膜病变。

非胰岛素依赖型糖尿病患者的糖尿病视网膜病变发病情况与此相似，但因不少患者发病日期难以确定，病程也更难估计。

一般说来，约1/4糖尿病患者有糖尿病视网膜病变，约5%有增殖性糖尿病视网膜病变。

糖尿病视网膜病变的发生和发展，不仅取决于代谢障碍的程度，也同时与糖尿病病程时间长短、患病年龄、遗传因素以及患者血糖控制状况等有关。

一般而言，随着糖尿病病程的延长和患者年龄的增加，各种类型的DR患病率均随之提高。

糖尿病病史20年以上，几乎99%的IDDM患者和60%的NID-DM都会有不同程度的DR发生；患糖尿病30年以上的患者中，约25%患增殖性糖尿病视网膜病变，约2%〜7%因视网膜病变失明。

糖尿病控制与并发症研究(DCCT)结果表明，加强血糖控制可降低视网膜病变危险性，并减缓IDDM患者视网膜病变的发展，加强血糖控制还可减慢严重非增生型或增生型DR的进展，降低黄斑水肿的发生率。

Wisconsin 进行的流行病学研究(WESDR)也显示降低血糖可降低IDDM和NIDDM患者的DR发生和发展。

糖尿病视网膜病变：专家共识解读

糖尿病视网膜病变：专家共识解读糖尿病视网膜病变（Diabetic Retinopathy，简称DR）是糖尿病最常见的微血管并发症之一，我国糖尿病患者已超过1亿，其中约30%～40%的患者伴有视网膜病变。

这一严峻形势促使我国眼科学界对糖尿病视网膜病变进行了深入研究，并形成了专家共识。

专家共识指出，糖尿病视网膜病变的病理机制主要包括微循环障碍、神经功能障碍和纤维组织增生。

微循环障碍导致视网膜毛细血管壁损伤，神经功能障碍使视网膜神经细胞受损，纤维组织增生则导致视网膜病变加重。

在糖尿病视网膜病变的早期阶段，患者可能没有任何自觉症状，但通过眼底检查可以发现微血管病变。

随着病情的进展，患者可出现视力模糊、视物变形等症状。

此时，糖尿病视网膜病变已进入中晚期，治疗难度较大，视力恢复效果不佳。

专家共识强调，早期筛查和干预是预防糖尿病视网膜病变的关键。

对于糖尿病患者，建议在确诊后立即进行眼底检查，以后每隔1～2年进行一次复查。

对于高风险患者，如年龄大于60岁、病程较长、血糖控制不佳等，应缩短筛查间隔。

在治疗方面，专家共识推荐了多种治疗方法，包括药物治疗、激光治疗和手术治疗。

药物治疗主要用于早期糖尿病视网膜病变，如抗血管内皮生长因子（VEGF）药物、抗血小板药物等。

激光治疗是糖尿病视网膜病变中晚期患者的首选治疗方法，通过激光凝固病变区域，减轻视网膜病变程度。

手术治疗主要用于严重糖尿病视网膜病变患者，如玻璃体切割术、视网膜移植等。

让我们通过一个实际案例来进一步了解糖尿病视网膜病变的防治。

张先生，50岁，糖尿病患者，因“视力下降”就诊。

经检查发现，张先生患有糖尿病视网膜病变，处于早期阶段。

医生建议他进行眼底检查，并定期复查。

同时，给予抗VEGF药物治疗，以减轻视网膜病变程度。

张先生遵循医嘱，定期复查并接受药物治疗，病情得到有效控制。

重点和难点解析：在上述文档中，有几个关键细节需要我们特别关注。

糖尿病视网膜病变（DR）是糖尿病最常见的微血管并发症之一。

糖尿病视网膜病变防治专家共识要点

糖尿病视网膜病变防治专家共识要点1.糖尿病视网膜病变的定义和分类：- 无增生性糖尿病视网膜病变：表现为微血管病变，包括微aneurysms、微出血、渗出和硬渗。

-非增生性糖尿病视网膜病变：包括球形硝石、瞳孔很小的硝石和硝石的穿透背景的硝石。

-增生性糖尿病视网膜病变：表现为异常新生血管、纤维增生和玻璃膜病变。

2.糖尿病视网膜病变的筛查：-所有类型的糖尿病患者应该接受视网膜筛查，糖尿病确诊后即可开始筛查。

-年轻人在糖尿病确诊后5年开始筛查；2型糖尿病患者从确诊时开始筛查，同时每3年作为保持较好血糖控制的指标。

-对于已经发展为增生性糖尿病视网膜病变的患者，需要更加频繁的筛查。

3.血糖控制：-严格控制血糖水平是预防和治疗糖尿病视网膜病变的关键。

-目标为：糖化血红蛋白（HbA1c）＜7%。

4.血压控制：-控制血压有助于降低糖尿病视网膜病变的风险。

- 血压目标为：一般情况下收缩压＜140 mmHg，舒张压＜90 mmHg；对于有糖尿病肾病（肾病或高蛋白尿）的患者，收缩压＜130 mmHg，舒张压＜80 mmHg。

5.使用药物：-血管紧张素转化酶抑制剂（ACEI）和血管紧张素受体拮抗剂（ARB）可用于降低糖尿病视网膜病变的风险。

-阿司匹林的应用不推荐作为糖尿病视网膜病变的一线治疗。

6.激素治疗：-对于增生性糖尿病视网膜病变患者，可考虑激素治疗，如激素植入物或激素注射。

7.准确诊断：-患者的病史和眼底检查结合起来，有助于糖尿病视网膜病变的准确诊断。

-针对不同类型的病变，应制定相应的治疗计划。

8.注射与激光治疗：- 对于一些患有增生性糖尿病视网膜病变的患者，可进行注射治疗，包括抗血管内皮生长因子（anti-VEGF）药物和糖皮质激素。

-激光治疗可用于治疗增生性糖尿病视网膜病变，可减少异常新生血管的产生和脱落。

9.手术治疗：-对于增生性糖尿病视网膜病变患者，手术治疗可作为一种选择。

-自发玻璃膜摘除和玻璃膜切割术是常见的手术治疗方法。

2020年美国眼科学会《糖尿病视网膜病变临床指南》解读(全文)

2020年美国眼科学会《糖尿病视网膜病变临床指南》解读（全文）摘要世界糖尿病患病人数逐年升高，中国糖尿病的患病率居于首位。

糖尿病视网膜病变(diabetic retinopathy，DR)作为糖尿病的重要微血管并发症，已经成为当今工作年龄人群中主要的致盲眼病之一，对社会和家庭带来了极大的负担。

近年来，多项基础及临床研究都在进行DR发病及治疗的探讨。

美国眼科学会于2019年发布了最新版DR临床指南，该版指南对上一版本指南进行了补充及修订，对DR的定义、流行病学、分类、检查以及诊断治疗等方面进行了详细的介绍。

本文将对2019版指南进行全面的解读，以期规范眼科医师对DR的认识、诊断和治疗，从而更好地减轻患者家庭和社会负担。

美国眼科学会于2019年发布了最新版糖尿病视网膜病变(diabetic retinopathy，DR)临床指南，该版指南在2017版指南的基础上进行了补充及修订[1]。

为规范眼科医师对DR的认识、诊断和治疗，本文对该新版指南中DR的定义、流行病学、分类、检查以及诊断治疗等方面进行了详细的解读。

1 DR的定义美国眼科学会在最新的指南中将DR定义为1型和2型糖尿病的常见并发症，是糖尿病患者终末器官损害的眼部表现，其中神经变性被认为是其发病的早期病理改变[2]。

DR常见的早期临床表现包括微动脉瘤形成和视网膜内出血，微血管损伤可以导致血管的通透性增加(视网膜水肿与渗出)，在增生阶段会导致视盘、视网膜、虹膜以及房角内的新血管增生，最终导致牵拉性视网膜脱离和新生血管性青光眼。

目前主要有两种糖尿病：1型糖尿病胰腺细胞介导的自身免疫性破坏，导致严重的胰岛素缺乏症；2型糖尿病患者通常是相对胰岛素缺乏，该类型占所有糖尿病患者的90%～95%，该类型中因DR而视力受损的患者所占比例也较高。

新版指南鼓励患者、基层医生以及专科医生相互协作，特别关注血糖[糖化血红蛋白(glycosylated hemoglobin，HbA1c)]、血压、血脂、体重的控制、肾脏疾病、冠状动脉疾病和神经病变的管理，并提供对于DR 的终身监测，治疗因DR导致视力下降或有下降危险的患者，尽可能减少治疗的不良反应，向视力障碍患者提供视力康复服务，并开发远程医疗改进的新技术。

指南共识l2020ADA诊疗标准-糖尿病视网膜病变（11-4）

指南共识l2020ADA诊疗标准-糖尿病视网膜病变（11-4）**CK注：2020版ADA糖尿病诊治标准于2019年末发布，该2020标准总体延续了2019版本的架构和基本内容。

CK经典文献翻译组在2019版标准的中文译文基础上（链接: 指南共识l 2019ADA 糖尿病医学诊疗标准（目录+中文译文全文链接）），开始2020版ADA糖尿病医学诊治标准的翻译。

2019版中文译文约18万字，本公众号曾断断续续用时长达10个月完成，此次将由CK翻译组各位老师更新为2020版本，可望更快速呈现于大家面前，会陆续发布于公众号内，另外也欢迎有余力的专业医生加入CK经典文献翻译组2020标准已发译文部分：•指南共识l 2020ADA诊疗标准-改善人群管理，促进人群健康（01）**•指南共识l 2020ADA诊疗标准-综合医学评估和合并症评估（04）**•指南共识 l 2020ADA诊疗标准-促进行为改变和心理健康以改善健康结局（05）**•指南共识 l 2020ADA诊疗标准-糖尿病技术（07）**•指南共识l 2020ADA诊疗标准-管理肥胖以治疗2型糖尿病（08）**•指南共识l 2020ADA诊疗标准-糖尿病和高血压/血压控制（10-1）**•指南共识 l 2020ADA诊疗标准-老年糖尿病（12）**•指南共识 l 2020ADA诊疗标准-儿童和青少年糖尿病（13）** •指南共识 l 2020ADA诊疗标准-院内血糖管理（15）**ADA 糖尿病诊治标准2020第十一部分 l 微血管并发症和足护理Microvascular Complications and Foot Care翻译：李莉/陈康CK经典文献翻译组李莉简介•副主任医师，硕士研究生，毕业于中南大学湘雅医学院•社会任职：山西省医师协会内分泌分会委员、山西省免疫学会内分泌代谢免疫学专委会委员、山西省医师学会甲状腺疾病专业委员会委员、山西省专家学者协会内分泌分会委员、长治市医师协会内分泌医师分会常委、长治医学会内分泌专家委员会甲状腺学组委员•发表国家级和省级论文10余篇、编写论著1部•获奖荣誉：“春天计划”病例大赛山西赛区一等奖、长治医学院第二临床学院双语教学比赛一等奖、长治医学院双语教学大赛二等奖、“德医双馨”病例大赛山西赛区二等奖、“秀霖解泌”病历大赛山西赛区二等奖美国糖尿病协会(ADA)“糖尿病医疗保健标准”包括：ADA当前的临床实践建议，旨在提供糖尿病诊治的相关内容、一般治疗目标和指南以及评估诊治质量的工具。

糖尿病视网膜病变-fw

非增殖性的糖尿病视网膜病变
硬性渗出
棉绒斑
机理 ---毛细血管闭塞，retina 缺血缺氧，导致视神经纤维肿胀断裂 ---轴浆流受损而形成白色羽毛状眼底表现 ---白色棉絮样团块，常位于血管分叉处是 retina 缺血、缺氧加重的标志
视网膜渗出
硬性渗出
棉绒斑(软性渗出)
水肿
机理 ---血管屏障功能受损，液体渗出（细胞外水肿）导致retina edema , 以macula最容易受累眼底表现 ---retina 局部或广泛灰白色增厚，macula中心反射消失，严重者形成囊样水肿
糖尿病性视网膜病变:视网膜出血，渗出，水肿糖尿病性视神经病变:视乳头水肿糖尿病性黄斑病变:黄斑出现水肿
•视网膜血管改变管径变化视网膜动脉硬化改变血管白鞘和白线状异常血管
•视网膜色素改变
•视网膜变性性改变视网膜色素变性周边视网膜变性
•视网膜增生性病变视网膜新生血管膜视网膜增生膜
（1984年6月第一届全国眼底病学术会议提出,经第三届全国眼科学术会议讨论通过）
红黄白
灰白色软性渗出或合并Ⅰ期或/和Ⅱ期病变
微血管瘤
视网膜微循环障碍最早的体征周细胞丧失，管壁薄弱，局部膨出呈囊样眼底表现边境清楚，红或暗红色斑病理视网膜毛细血管前小动脉毛细血管、毛细血管后小动脉管壁呈球形或卵圆形侧膨隆 ---多少和变化反映了病变轻重和进展 ---并非糖尿病所特有
眼底荧光血管造影
提供更精确的信息 1、病变早期可显示微血管瘤、视网膜血管功能失调 2、判断黄斑水肿的程度,并观察其病变有无缺血改变 3、发现早期新生血管、引导激光治疗及疗效评估
荧光素渗漏
点状出血
斑片状出血

眼底病的人工智能研究

眼底病的人工智能研究第一节基于眼底彩照的智能诊断技术概况一、发展历史世界卫生组织2019年10月发布的统计数据显示，全世界有超过4.18亿人患有青光眼、糖尿病视网膜病变、年龄相关性黄斑变性或其他可导致失明的眼病。

眼底彩照是由单目照相机在2D平面上捕获的眼底投影。

并且与光学相干断层扫描图像和血管造影图像等其他扫描成像方式不同，眼底彩照可以以非侵入性的和经济有效的方式获得，更适合大规模筛查。

在眼底彩照中可以直观地观察到许多重要的生物标志物，如视盘、视杯、黄斑、视网膜中央凹、眼底血管以及其他一些与糖尿病视网膜病变相关的病灶（如微动脉瘤、出血和渗出等）。

因此眼底彩照可以用于诊断多种眼部疾病，眼部的定期筛查也有助于眼部疾病的早期诊断和及时干预治疗。

由于具有专业眼图像分析能力的眼科医生数量相对较少，而需要阅读的眼图像的数量较多，因而对有限的临床资源造成了极大的压力。

并且考虑到人工阅读大量眼图像会受到疲劳和主观因素的影响，不同医生的诊断结果可能不一致，从而导致眼疾病的误诊率升高。

因此，为了在提升眼疾病诊断准确性的同时减轻医生的诊断负担，眼底彩照的计算机辅助诊断技术越发受到人们的关注。

对眼底彩照的分析研究可以追溯到1973年Matsui等发表的《眼底照片的自动定量诊断研究：在彩色眼底照片上检测视网膜血管图像的轮廓线》，这是世界上首个将数学形态学方法应用于视网膜眼底图像的分析研究。

对医学图像计算机辅助诊断技术的大规模系统性研究和开发最早开始于20世纪80年代早期，1984年Baudoin等在发表的《自动检测糖尿病荧光血管造影中的微血管瘤》一文中提出了检测糖尿病视网膜病变损伤的图像分析方法。

眼图像处理技术的提升大大推动了眼疾病自动诊断系统的发展，计算机辅助诊断系统使大规模的疾病筛查成为可能，在有效节约资源的同时，大大减轻了医生的诊断负担。

21世纪初，随着成像技术和信息技术的不断发展，机器学习领域涌现的各类经典算法被应用于眼底彩照的智能诊断。

《糖尿病视网膜病变防治专家共识》要点

《糖尿病视网膜病变防治专家共识》要点糖尿病视网膜病变（diabeticretinopathy，DR）是常见的糖尿病慢性并发症之一，也是导致成人失明的主要原因之一。

DR严重威胁着糖尿病患者的生存质量，同时给社会带来严重经济负担。

一、DR的流行情况DR因国家、地区、种族而异，发展中国家较发达国家患病率低。

二、DR的危险因素DR的主要危险因素包括高血糖或明显血糖波动、高血压、高血脂、糖尿病病程长、糖尿病肾病（DKD）、妊娠、肥胖、易感基因等（表1）。

三、DR的筛查与转诊DR的早期诊断、早期治疗可显著减少失明的风险，部分DR或糖尿病性黄斑水肿(DME)患者可以无症状，因此医师必须重视且积极开展DR筛查并及时管理（图1）。

（一）筛查1. 筛查方法：免散瞳眼底摄片筛查DR具有较好的灵敏度和特异度，高质量的眼底照片可以筛查出绝大多数有临床意义的DR。

本共识推荐内分泌科医师采用免散瞳眼底摄片筛查DR，同时建议内分泌科医师和有经验的眼科医师共同阅片。

但是应当指出，免散瞳眼底摄片不能完全替代全面的眼科检查，譬如无法有效筛查DME。

若出现严重的DME或中度非增生期以上的DR征象，建议在眼科医师处行光学相干断层成像和荧光素眼底血管造影检查，必要时行眼底超声检查。

2. 筛查时机：我国建议青春期前或青春期诊断的1型糖尿病患者在青春期后（12岁后）开始检查眼底，青春期后诊断1型糖尿病的患者建议在病程5年内，必须进行第一次DR筛查。

2型糖尿病患者则建议在确诊后尽快进行首次全面的眼科检查。

已确诊糖尿病的患者，妊娠期间视网膜病变有发生发展的风险，应于计划妊娠和妊娠早期进行全面眼科检查。

特别指出，妊娠期确诊糖尿病的患者发生DR的风险不增高，因此孕期不需要进行眼底检查。

2型糖尿病伴发微量白蛋白尿或肾小球滤过率下降者需检查有无DR。

3. 筛查频率：1型糖尿病患者开始筛查DR后建议至少每年复查一次，2型糖尿病无DR者推荐每1～2年检查一次。

美国糖尿病协会(ADA)糖尿病诊疗指南

2012年ADA糖尿病诊疗指南美国糖尿病协会目前糖尿病的诊断标准A1C≥6。

5％。

试验应该用美国糖化血红蛋白标准化计划组织（National Glycohemoglobin Standardization Program，NGSP）认证的方法进行,并与糖尿病控制和并发症研究(Diabetes Control and Complications Trial，DCCT)的检测进行标化。

或空腹血糖（FPG）≥7.0 mmol/L.空腹的定义是至少8小时未摄入热量。

或OGTT 2h血糖≥11.1 mmol/L。

试验应按世界卫生组织（WHO)的标准进行，用相当于75 g无水葡萄糖溶于水作为糖负荷。

或在有高血糖的典型症状或高血糖危象的患者，随机血糖≥11。

1 mmol/L。

如无明确的高血糖,结果应重复检测确认。

在无症状患者中进行糖尿病筛查在无症状的成人,如超重或肥胖（BMI≥25kg/m2）并有一个以上其他糖尿病危险因素（见“2012年糖尿病诊疗标准”中的表4），应该从任何年龄开始筛查糖尿病并评估将来糖尿病的风险。

对没有这些危险因素的人群,应从45岁开始筛查。

（B）如果检查结果正常,至少每3年复查一次。

（E）为筛查糖尿病或评估未来糖尿病的风险，A1C、 FPG或2h 75g OGTT均可使用。

（B）对于那些已经明确未来糖尿病风险增加的人群，应该进一步评估并治疗其他心血管疾病（CVD）危险因素。

（B）妊娠期糖尿病的筛查和诊断在有危险因素的个体中，产前首次就诊时用标准的诊断方法筛查未诊断的2型糖尿病。

（B）未知是否具有糖尿病的孕妇，在妊娠24～28周用75g 2h OGTT 筛查妊娠糖尿病，诊断切点见“2012年糖尿病诊疗标准”表6。

（B）妊娠糖尿病的妇女在产后6～12周用除A1C以外的方法筛查永久性糖尿病.(E）有妊娠糖尿病病史的妇女应至少每3年筛查是否发展为糖尿病或糖尿病前期。

（B) 如发现有妊娠糖尿病病史的妇女为糖尿病前期,应接受生活方式干预或二甲双胍治疗以预防糖尿病（A)预防/延缓2型糖尿病对于糖耐量异常（IGT）（A）、空腹血糖受损（IFG）（E)或A1C 在5.7~6。