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National Collaborating Centre for Chronic Conditions (UK). Type 2 Diabetes: National Clinical Guideline for Management in Primary and Secondary Care (Update). London: Royal College of Physicians (UK); 2008. (NICE Clinical Guidelines, No. 66.)

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Type 2 Diabetes: National Clinical Guideline for Management in Primary and Secondary Care (Update).

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17Eye damage

Diabetes eye damage is the single largest cause of blindness before old age with a progressive incidence in people with Type 2 diabetes.346 The success of laser therapy in the treatment of sight-threatening retinopathy is an accepted part of ophthalmological care and has not been assessed for this guideline.

Appropriate clinical questions to be addressed are, however, how people with developing retinopathy can be selected for ophthalmological referral in time for optimal treatment, and whether preventative therapy other than good blood glucose, good blood pressure, and good blood lipid control can be useful in people with Type 2 diabetes.

17.1.1. Methodological introduction

It was noted that management in this area was largely determined by practice for all people with diabetes and not just those with Type 2 diabetes. Indeed retinopathy screening programmes to be provided on a local community basis were a key early target of the National Service Framework (NSF) for diabetes, and since that time the UK National Screening Programme has published and updated a workbook on ‘Essential elements in developing a diabetic retinopathy screening programme’ for the guidance of health authorities and primary care trusts in England (fourth edition, January 2007).347

These observations, and a lack of awareness amongst experts of new publications that might affect recommendations on retinopathy screening, led to the conclusion that recommendations for people with Type 2 diabetes should closely follow those for Type 1 diabetes (NICE guideline 2004),26 which themselves were largely based on generic evidence independent of type of diabetes.

Accordingly the recommendations of the Type 1 diabetes guidelines, and the evidence statements underlying them were reviewed, together with the national screening document. There are no significant changes from the Type 1 diabetes recommendations.



Arrange or perform eye screening at, or around, the time of diagnosis. Arrange repeat of structured eye surveillance annually.


Explain the reasons for and success of eye surveillance systems to the individual and ensure attendance is not reduced by ignorance of need, or fear of outcome.


Use mydriasis with tropicamide when photographing the retina, after prior informed agreement following discussion of the advantages and disadvantages. Discussions should include precautions for driving.


Use a quality assured digital retinal photography programme using appropriately trained staff.


Perform visual acuity testing as a routine part of eye surveillance programmes.


Repeat structured eye surveillance according to the findings by:

  • routine review in 1 year, or
  • earlier review, or
  • referral to an ophthalmologist.

Arrange emergency review by an ophthalmologist for:

  • sudden loss of vision
  • rubeosis iridis
  • pre-retinal or vitreous haemorrhage
  • retinal detachment.

Arrange rapid review by an ophthalmologist for new vessel formation.


Refer to an ophthalmologist in accordance with the National Screening Committee criteria and timelines if any of these features is present:

  • referable maculopathy:

    exudate or retinal thickening within one disc diameter of the centre of the fovea

    circinate or group of exudates within the macula (the macula is defined here as a circle centred on the fovea, with a diameter the distance between the temporal border of the optic disc and the fovea)

    any microaneurysm or haemorrhage within one disc diameter of the centre of the fovea, only if associated with deterioration of best visual acuity to 6/12 or worse.

  • referable pre-proliferative retinopathy (if cotton wool spots are present, look carefully for the following features, but cotton wool spots themselves do not define pre-proliferative retinopathy):

    any venous beading

    any venous loop or reduplication

    any intraretinal microvascular abnormalities

    multiple deep, round or blot haemorrhages

  • any unexplained drop in visual acuity.
Copyright © 2008, Royal College of Physicians of London.

All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher.

Bookshelf ID: NBK53889
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