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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.

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grading criteria changes new pathway 2012

Grading Criteria Changes New Pathway 2012

Robert Brown & Yvonne D’Souza

SMDESP – June 2012

how will it effect smdesp
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
grading changes in the new pathway
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
The R2 Pre-proliferative level
  • Venous beading
  • Venous reduplication
  • Multiple blot haemorrhages
  • IRMA
    • New definition
opdr pathway
OPDR Pathway
  • Pregnant women
  • Patients who require increased level of surveillance
  • Patients discharged from HES
  • More frequent photography + OCT
irma intraretinal microvascular abnormalities
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
Grading IRMA
  • Only IRMA that are definitely seen should be referred
  • Once 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
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 diabetic retinopathy
R3 (Proliferative Diabetic Retinopathy)

R3 will be split into

  • R3a (Active Proliferative Retinopathy)


  • R3s (Stable Treated Proliferative Retinopathy)
r3s 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.
  • 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.
revised definition of a group of exudates
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
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
revision to classification of image quality
Revision to Classification of Image Quality
  • 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.
adequate 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
  • 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.
  • Date not yet set – software modifications
  • TAT test sets – likely to change in October 2012


Peter Scanlon

Programme Director, NHS Diabetic Eye Screening Programme

Ophthalmologist, Gloucestershire and Oxford Eye Unit

thanks for listening

Thanks for listening!

Any Questions?