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

Grading Criteria Changes New Pathway 2012

Robert Brown & Yvonne D’Souza

SMDESP – June 2012

New Pathway diagram

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

Retinopathy Grading Criteria

R0 None No DR

R1 Background microaneurysm(s) or HMa*

retinal haemorrhage(s)

venous loop

any exudate in the presence of other non-referable features of DR

any number of cotton wool spots (CWS) in the presence of other non-referable features of DR

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)

The R2 Pre-proliferative level

Venous beading

Venous reduplication

Multiple blot haemorrhages

IRMA New definition

OPDR Pathway

Pregnant women

Patients who require increased level of surveillance

Patients discharged from HES

More frequent photography + OCT

Referable

Referable

Referable

Not referable

Not referable

Not referable

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.

Grading IRMA

Only IRMA that are definitely seen should be referredOnce 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).

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.

R3 Proliferative Grading CriteriaR3 Proliferative R3a

(Active Proliferative Retinopathy)

All newly occurring R3 patients with:

new vessels on disc (NVD)

new vessels elsewhere (NVE)

pre-retinal or vitreous haemorrhage

pre-retinal fibrosis tractional retinal detachment

R3s (Stable post

treatment)

Evidence of Peripheral Retinal Laser Treatment AND

Stable retina from photograph taken at or shortly after discharge from the Hospital Eye service (HES)

R3 will be split into

R3a (Active Proliferative Retinopathy)

and

R3s (Stable Treated Proliferative Retinopathy)

R3 (Proliferative Diabetic Retinopathy)

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

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.

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.

R3s

Maculopathy Grading CriteriaM0 No

maculopathyabsence of any M1 features

M1 Maculopathy exudate within 1 disc diameter (DD) of the centre of the fovea

M1 - list of features as now - but individual features are not mutually exclusive

group of exudates within the macula

retinal thickening within 1DD of the centre of the fovea (if stereo available)

any microaneurysm or haemorrhage within 1DD of the centre of the fovea only if associated with a best VA of 6/12 (if no stereo)

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

Referable

Referable

Not Referable

Not Referable

Wet AMD

Any images with signs of wet AMD should be referred via the local wet AMD service

MREH – MARRC clinic

SHH – Urgent ref to SHH – referral co-ordinator

Photocoagulation

P Photocoagulation

No evidence of previous photocoagulation

No grade is assigned

P focal/grid to macula or peripheral scatter

Only assigned if laser scars are identified

U Unclassifiable

U An image set that is inadequate for grading

The main change will be that there will no longer be a ‘Good’ category, just ‘Adequate’ and ‘Inadequate’.

The concept of ‘jig sawing’ is introduced, which is where a series of images can be combined to provide retinal views of the same areas as adequate macular and nasal images.

Revision to Classification of Image Quality

Adequate Image Quality

Macular imagecentre of fovea >2DD from edge of image& vessels visible within 1DD of centre of foveaandDisc imagecomplete optic disc >2DD from edge of image& fine vessels visible on surface of disc

Inadequate Image Quality

Inadequate Image Quality – failure to meet definition of adequate above

If sight threatening retinopathy (STDR) is present on any image, the eye should be graded as adequate and patient referred to HES.

Absence of a macula or disc / nasal image for the eye means the fields are inadequate for grading except if criteria in point 1 is fulfilled.

if fine vessels are visible within 1DD of centre of fovea on any image available and fine vessels are visible on the surface of disc on any image available, the eye can be graded for R and M level. This could be by ‘jig sawing’ a series of images so that an adequate view is obtained of critical areas.

Implementation

Date not yet set – software modifications

TAT test sets – likely to change in October 2012

Acknowledgement

Peter ScanlonProgramme Director, NHS Diabetic Eye Screening

ProgrammeOphthalmologist, Gloucestershire and Oxford Eye Unit

Thanks for listening!

Any Questions?