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Management of type 2 diabetes: A handbook for general practice
Last revised: 17 Sep 2020
Grade: A, level 1
Grade: D, consensus
Grade: None provided level IV evidence
Grade: A, level 1A
Grade: A, level 1A
Diabetes-related retinopathy (DR) occurs as a result of microvascular disease of the retina. It affects up to one in three people with diabetes, and can cause visual impairment and blindness.5 DR also impairs quality of life and ability to manage diabetes.6
Sight-threatening DR includes:
Non-proliferative DR affects 19.3% of people with diabetes, while 2.1% may have proliferative DR and 3.3% may have macular oedema.7 Proliferative DR and macular oedema are associated with elevated cardiovascular disease risk.8
Risk factors for the onset or progression of DR include:
Visual impairment due to diabetes can be avoided for the vast majority of patients through good screening and care. This involves regular review of fundi, early detection and optimisation of therapy.
Monitoring for diabetic eye disease involves assessment of:
Screening methods and intervals for retinopathy are shown in Box 1.
Strategies for delaying the onset and progression of DR include:
KeepSight is a free online reminder system for people with diabetes about their next diabetes eye examination. It is managed by Diabetes Australia and Vision 2020.
The National Diabetes Services Scheme (NDSS) and Diabetes Australia send alerts and reminders to people with diabetes registered on the NDSS to have their eyes checked.
If retinopathy is not present
Rescreen every year:3
Rescreen every two years:3
Review glycaemic, blood pressure and lipid control, and adjust therapy to reach targets as per guidelines
Screen for other diabetes complications
For more information, refer to the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) screening and referral algorithm for diabetic retinopathy.
*Treatment options include fenofibrate, laser therapy, intra-ocular anti-VEGF agents, vitreoretinal surgery.
Retinal photography is technically simple and is now usually performed within the Australian community by general practitioners, optometrists and ophthalmologists. Training is required to ensure quality of image interpretation.
Aboriginal health services are providing their own retinal photography services with support through telemedicine to promote access to screening.
People whose retinal images suggest they may be at increased risk of having, or at some point developing, sight-threatening retinopathy should be referred for assessment by an ophthalmologist.
Retinal photography may serve as a screening tool for retinopathy; however, it is not a substitute for a comprehensive eye exam.4
Note: A Medicare Benefits Schedule (MBS) item number for retinal photography with a non‑mydriatic retinal camera is available for general practice use.
Refractive errors occur as the lens shape alters with changes in blood glucose concentrations and results in blurred vision. Correction of refractive errors should be postponed until blood glucose levels are stabilised. Detection is done with pinhole test – blurred vision due purely to refractive error corrects with the pinhole test.
Cataracts occur prematurely in people with diabetes. Patients present with blurred vision and glare intolerance, and may find night vision a particular problem. Over time, interpretation of colours becomes more difficult.
Clinically, the light reflex is reduced, and fundus may be difficult to see.
Surgical treatment is recommended when reduced acuity is affecting lifestyle and independence.
Maculopathy other than oedema is difficult to diagnose ophthalmoscopically; however, it is the most common cause of vision loss in people with diabetes.
The incidence of glaucoma in people with diabetes is approximately twice that of the general population. All patients with type 2 diabetes should be monitored for glaucoma.16
Ischaemic optic neuropathy is a cause of sudden vision loss and has a poor prognosis for sight.
Sudden loss of vision is an emergency, and may be caused by:
These conditions can occur independently of diabetes. Urgent contact with an ophthalmologist or timely assessment by a specialist team is indicated
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Type 2 diabetes: Goals for optimum management (PDF 0.04 MB)
Australian type 2 diabetes management algorithm - updated August 2022 (PDF 1.46 MB)
Management of type 2 diabetes: A handbook for general practice - Clinical summary (PDF 0.24 MB)
Diabetes management during the coronavirus pandemic (PDF 1.53 MB)
Diabetes management during Ramadan (PDF 1.83 MB)
Emergency management of hyperglycaemia in primary care (PDF 1.44 MB)
Type 2 diabetes sick day management plan - template (DOCX 0.07 MB)
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