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## Complete Summary

#### GUIDELINE TITLE

Diabetic retinopathy.

#### BIBLIOGRAPHIC SOURCE(S)

American Academy of Ophthalmology Retina Panel, Preferred Practice
Patterns Committee. Diabetic retinopathy. San Francisco (CA): American
Academy of Ophthalmology (AAO); 2003. 33 p. \[98 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Academy of
Ophthalmology (AAO), Preferred Practice Patterns Committee, Retina
Panel. Diabetic retinopathy. San Francisco (CA): American Academy of
Ophthalmology (AAO); 1998. 32 p.

All Preferred Practice Patterns are reviewed by their parent panel
annually or earlier if developments warrant.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Diabetic retinopathy

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Ophthalmology

#### INTENDED USERS

Health Plans\
Physicians

#### GUIDELINE OBJECTIVE(S)

To prevent, retard, or reverse visual loss, thereby maintaining or
improving vision-related quality of life by addressing the following
goals:

-   Identify patients at risk of 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

#### TARGET POPULATION

Persons with diabetes mellitus

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Comprehensive adult medical eye evaluation

2.  Medical history, including duration of disease, history of glycemia
    control, and medications

3.  Examination, including best-corrected visual acuity, intraocular
    pressure, gonioscopy, slit-lamp biomicroscopy, dilated fundoscopy
    including stereoscopic examination of the posterior pole, and
    examination of the peripheral retina and vitreous

4.  Ancillary tests, including color fundus photography, fluorescein
    angiography, ultrasonography, and optical coherence tomography

**Treatment**

1.  Laser photocoagulation surgery (scatter, focal, or grid)

2.  Color fundus photography

3.  Fluorescein angiography

4.  Other treatments, including intravitreal administration of
    corticosteroids, protein kinase C inhibitors, and growth hormone
    antagonists, which are currently under investigation and are not
    currently recommended

5.  Vitrectomy

**Management**

1.  Follow-up care of patient

2.  Referral if appropriate

3.  Patient education

#### MAJOR OUTCOMES CONSIDERED

Patient outcome criteria include:

-   Visual function

-   Vision-related quality of life

-   Coordination of care management to achieve optimal glycemic control

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A detailed literature search of articles in the English language was
conducted on the subject of diabetic retinopathy for the years 1997 to
2002.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Ratings of Strength of Evidence**

I.  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.

II. Level II includes evidence obtained from the following:

    -   Well-designed controlled trials without randomization

    -   Well-designed cohort or case-control analytic studies,
        preferably from more than one center

    -   Multiple-time series with or without the intervention

III. Level III includes evidence obtained from one of the following:

     -   Descriptive studies

     -   Case reports

     -   Reports of expert committees/organization

     -   Expert opinion (e.g., Preferred Practice Pattern panel
         consensus)

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The results of a literature search on the subject of diabetic
retinopathy 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 panel also rated each recommendation on the strength
of the evidence in the available literature to support the
recommendation made.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Ratings of Importance to Care Process**

Level A, most important\
Level B, moderately important\
Level C, relevant but not critical

#### COST ANALYSIS

Computer-simulation models have been designed to predict the medical and
economic effects of applying accepted methods for controlling diabetic
retinopathy among type 1 patients. In one study, recommendations for
screening were taken from the Public Health Committee of the American
Academy of Ophthalmology. Surgery recommendations and modeled treatment
efficacy were drawn from the reports of the Diabetic Retinopathy Study
(DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS). Costs
of screening and surgery were drawn from published Medicare
reimbursement data.

The model predicted that over their lifetime, 72% of type 1 patients
will eventually develop proliferative diabetic retinopathy (PDR)
requiring panretinal photocoagulation and that 42% will develop macular
edema. If treatments are delivered as recommended in the clinical
trials, the model predicted a cost of \$966 per person-year of vision
saved from proliferative diabetic retinopathy and \$1120 per person-year
of central visual acuity saved from macular edema. In addition, if all
type 1 patients received eye care at federal expense, the predicted
savings exceed \$167.0 million and 79,236 person-years of sight. These
costs are less than the cost of a year of Social Security disability
payments for those disabled by vision loss. Therefore, treatment yields
a substantial savings compared with the direct cost to society of the
case of an untreated type 1 patient. The indirect costs, in lost
productivity and human suffering, are even greater.

A more recent analysis, using the same computer model, predicted the
cost-effectiveness of detecting and treating diabetic retinopathy from
the insurers\' perspective. Screening and treatment of eye disease in
diabetic patients costs, on average, \$3,190 per quality-adjusted
life-year (QALY) saved. For patients with type 1 diabetes, it costs
\$1,996 per QALY saved; for patients with type 2 diabetes who use
insulin, it costs \$2,933 per QALY saved; and for patients with type 2
diabetes who do not use insulin, it costs \$3,530 per QALY saved.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

These guidelines were reviewed by Council and approved by the Board of
Trustees of the American Academy of Ophthalmology (September 2003). All
*Preferred Practice Patterns* are reviewed by their parent panel
annually or earlier if developments warrant and updated accordingly.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*The ratings of importance to the care process, (A, B, C) and the
ratings for strength of evidence, (I, II, III) are defined at the end of
the \"Major Recommendations\" field.*

**Diagnosis**

The initial examination for a patient with diabetes mellitus includes
all features of the comprehensive adult medical eye evaluation, with
particular attention to those aspects relevant to diabetic retinopathy.

**History**

An initial history should consider the following elements:

-   Duration of diabetes \[A:I\]

-   Past glycemic control (hemoglobin A~1c~) \[A:I\]

-   Medications \[A:III\]

-   Medical history (e.g., onset of puberty, \[A:III\] obesity,
    \[A:III\] renal disease, \[A:II\] systemic hypertension, \[A:I\]
    serum lipid levels, \[A:II\] pregnancy \[A:I\])

**Examination**

The initial examination should include the following elements:

-   Best-corrected visual acuity \[A:I\]

-   Intraocular pressure \[A:III\]

-   Gonioscopy when indicated \[A:III\]

-   Slit-lamp biomicroscopy \[A:III\]

-   Dilated funduscopy including stereoscopic examination of the
    posterior pole \[A:I\]

-   Examination of the peripheral retina and vitreous \[A:III\]

Slit-lamp biomicroscopy with accessory lenses is the recommended method
to evaluate retinopathy in the posterior pole and midperipheral retina.
\[A:III\] The examination of the peripheral retina is best performed
with indirect ophthalmoscopy or with slit-lamp biomicroscopy, combined
with a contact lens. \[A:III\]

**Examination Schedule**

**Recommended Eye Examination Schedule for Patients with Diabetes
Mellitus**

  -----------------------------------------------------------------------
  **Diabetes      **Recommended Time of First **Recommended Follow-up\***
  Type**          Examination**               
  --------------- --------------------------- ---------------------------
  Type 1          5 years after onset         Yearly \[A:II\]
                  \[A:II\]                    

  Type 2          At time of diagnosis        Yearly \[A:II\]
                  \[A:II\]                    

  Prior to        Prior to conception or      No retinopathy to mild or
  pregnancy (type early in the first          moderate nonproliferative
  1 or type 2)    trimester \[A:I\]           diabetic retinopathy
                                              (NPDR): every 3-12 months
                                              \[A:I\]\
                                              \
                                              Severe NPDR or worse: every
                                              1-3 months \[A:I\]
  -----------------------------------------------------------------------

**\*Abnormal findings may dictate more frequent follow-up
examinations.**

**Treatment**

Management recommendations for patients with diabetic retinopathy are
summarized in the table below.

**Management Recommendations for Patients with Diabetes**

  -----------------------------------------------------------------------------------------------
  **Severity of      **Presence of **Follow-up   **Scatter       **Fluorescein   **Focal
  Retinopathy**      clinically    (Months)**    (Panretinal)    Angiography**   Laser^2^**
                     significant                 Laser**                         
                     macular edema                                               
                     (CSME^1^)**                                                 
  ------------------ ------------- ------------- --------------- --------------- ----------------
  1\. Normal or      No            12            No              No              No
  minimal NPDR                                                                   

  2\. Mild to        No\           6-12\         No\             No\             No\
  moderate NPDR      \             \             \               \               \
                     Yes           2-4           No              Usually         Usually^1,\ 3^

  3\. Severe or very No\           2-4\          Sometimes^4^\   Rarely\         No\
  severe NPDR        \             \             \               \               \
                     Yes           2-4           Sometimes^4^    Usually         Usually^5^

  4\. Non-high-risk  No\           2-4\          Sometimes^4^\   Rarely\         No\
  PDR                \             \             \               \               \
                     Yes           2-4           Sometimes^4^    Usually         Usually^3^

  5\. High-risk PDR  No\           3-4\          Usually\        Rarely\         No\
                     \             \             \               \               \
                     Yes           3-4           Usually         Usually         Usually^5^

  6\. High-risk PDR  \--           1-6           Not Possible^6^ Occasionally    Not Possible^6^
  not amenable to                                                                
  photocoagulation                                                               
  (e.g., media                                                                   
  opacities)                                                                     
  -----------------------------------------------------------------------------------------------

1.  Exceptions include: hypertension or fluid retention associated with
    heart failure, renal failure, pregnancy, or any other causes that
    may aggravate macular edema. Deferral of photocoagulation for a
    brief period of medical treatment may be considered in these cases.
    Also, deferral of CSME treatment is an option when the center of the
    macula is not involved, visual acuity is excellent, close follow-up
    is possible, and the patient understands the risks.

2.  Focal photocoagulation refers to direct focal laser to leaking
    microaneurysms or a grid photocoagulation pattern to areas of
    diffuse leakage or nonperfusion seen on fluorescein angiography.

3.  Deferring focal photocoagulation for CSME is an option when the
    center of the macula is not involved, visual acuity is excellent,
    close follow-up is possible, and the patient understands the risks.
    However, initiation of treatment with focal photocoagulation should
    also be considered because, although treatment with focal
    photocoagulation is less likely to improve the vision, it is more
    likely to stabilize the current visual acuity.

4.  Scatter (panretinal) photocoagulation surgery may be considered as
    patients approach high-risk PDR. The benefit of early scatter
    photocoagulation at the severe nonproliferative or worse stage of
    retinopathy is greater in patients with type 2 diabetes than in
    those with type 1. Treatment should be considered for patients with
    severe NPDR and type 2 diabetes. Other factors, such as poor
    compliance with follow-up, impending cataract extraction or
    pregnancy, and status of the fellow eye will help in determining the
    timing of the scatter photocoagulation.

5.  Some experts feel that it is preferable to perform focal
    photocoagulation first, prior to scatter photocoagulation, to
    minimize scatter laser-induced exacerbation of the macular edema.

6.  Vitrectomy is indicated in selected cases.

**Follow-up**

The follow-up evaluation includes a history and examination.

**History**

A follow-up history should include changes in the following:

-   Symptoms \[A:III\]

-   Systemic status (pregnancy, blood pressure, renal status) \[A:III\]

-   Glycemic status (hemoglobin A~1c~) \[A:I\]

**Examination**

A follow-up examination should include the following elements:

-   Visual acuity \[A:I\]

-   Intraocular pressure \[A:III\]

-   Slit-lamp biomicroscopy with iris examination \[A:II\]

-   Gonioscopy (if iris neovascularization is suspected or present or if
    intraocular pressure is increased) \[A:II\]

-   Stereo examination of the posterior pole with dilation of the pupils
    \[A:I\]

-   Peripheral retina and vitreous examination, when indicated \[A:II\]

Recommended intervals for follow-up are given in the above table.

**Provider**

Because of the complexities of the diagnosis and surgery for PDR, the
ophthalmologist caring for patients with this condition should be
familiar with the specific recommendations of the Diabetic Retinopathy
Study (DRS), Early Treatment Diabetic Retinopathy Study (ETDRS), United
Kingdom Prospective Diabetes Study (UKPDS), and Diabetes Control and
Complications Trial (DCCT). \[A:III\] The ophthalmologist should also
have training in and experience with the management of this particular
condition. \[A:III\]

**Counseling/Referral**

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. \[A:III\]

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 for diabetic retinopathy depends on timely
intervention, despite good vision and no ocular symptoms. \[A:III\]

Those patients whose conditions fail to respond to surgery and those for
whom further treatment is unavailable should be provided with proper
professional support and offered referral for counseling, vision
rehabilitation, or social services as appropriate. \[A:III\]

**Definitions**:

**Ratings of Importance to Care Process**

Level A, most important\
Level B, moderately important\
Level C, relevant but not critical

**Ratings of Strength of Evidence**

I.  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.

II. Level II includes evidence obtained from the following:

    -   Well-designed controlled trials without randomization

    -   Well-designed cohort or case-control analytic studies,
        preferably from more than one center

    -   Multiple-time series with or without the intervention

III. Level III includes evidence obtained from one of the following:

     -   Descriptive studies

     -   Case reports

     -   Reports of expert committees/organization

     -   Expert opinion (e.g., Preferred Practice Pattern panel
         consensus)

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations.\")

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Effective evaluation and management of diabetic retinopathy resulting in
prevention, retardation, or reversal of visual loss and improved
vision-related quality of life

#### POTENTIAL HARMS

**Focal Laser Photocoagulation for Diabetic Macular Edema**

Focal laser photocoagulation for diabetic macular edema may result in an
initial decrease in central vision. Patients undergoing this treatment
should be informed of this possibility. Rarely, this treatment may
induce subretinal fibrosis with choroidal neovascularization (CNV),
which may be associated with permanent central vision loss. The most
important factors associated with subretinal fibrosis include the most
severe degree of subretinal hard exudates in the macula and elevated
serum lipids prior to laser photocoagulation. Only 8% of cases of
subretinal fibrosis were directly related to focal laser
photocoagulation. Laser photocoagulation causes disruption of the retina
with destruction of the photoreceptors. In cases where laser burns have
been placed close to the fovea, especially burns that are confluent, the
patient may be aware of paracentral scotomas. In addition, inadvertent
foveal burns may produce a permanent central scotoma. It is important to
avoid placing laser burns in or close to the center of the fovea.

**Scatter Photocoagulation for Severe Nonproliferative Diabetic
Retinopathy (NPDR) or Proliferative Diabetic Retinopathy (PDR)**

Scatter treatment was shown in the Diabetic Retinopathy Study (DRS) to
result in some central vision loss. Peripheral visual field
constrictions with poor dark adaptation are side effects of extensive
scatter photocoagulation treatment. In the presence of
neovascularization, the patient should be warned that vitreous
hemorrhage may occur during the course of scatter laser
photocoagulation.

**Vitrectomy**

Vitreous surgery has the potential for serious complications, including
recurrent vitreous hemorrhage, retinal detachment, and rubeosis iridis,
and these complications may result in severe visual loss and eye pain.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Foreign Language Translations\
Patient Resources\
Personal Digital Assistant (PDA) Downloads\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Academy of Ophthalmology Retina Panel, Preferred Practice
Patterns Committee. Diabetic retinopathy. San Francisco (CA): American
Academy of Ophthalmology (AAO); 2003. 33 p. \[98 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 Sep (revised 2003)

#### GUIDELINE DEVELOPER(S)

American Academy of Ophthalmology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Ophthalmology

#### GUIDELINE COMMITTEE

Preferred Practice Patterns Committee, Retina Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Retina Panel Members*: Emily Y. Chew, MD (*Chair*); William E. Benson,
MD; H. Culver Boldt, MD; Tom S. Chang, MD; Louis A. Lobes, Jr., MD; Joan
W. Miller, MD; Timothy G. Murray, MD; Marco A. Zarbin, MD, PhD; Leslie
Hyman, PhD (*Methodologist*)

*Preferred Practice Patterns Committee Members*: Joseph Caprioli, MD
(*Chair*); J. Bronwyn Bateman, MD; Emily Y. Chew, MD; Douglas E.
Gaasterland, MD; Sid Mandelbaum, MD; Samuel Masket, MD; Alice Y. Matoba,
MD; Donald S. Fong, MD, MPH

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

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.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Academy of
Ophthalmology (AAO), Preferred Practice Patterns Committee, Retina
Panel. Diabetic retinopathy. San Francisco (CA): American Academy of
Ophthalmology (AAO); 1998. 32 p.

All Preferred Practice Patterns are reviewed by their parent panel
annually or earlier if developments warrant.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Ophthalmology
(AAO) Web site](http://www.aao.org/education/guidelines/ppp/index.cfm).

Print copies: Available from American Academy of Ophthalmology, P.O. Box
7424, San Francisco, CA 94120-7424; telephone, (415) 561-8540.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Summary benchmarks for preferred practice patterns. San Francisco
    (CA): American Academy of Ophthalmology; 2006 Nov. 21 p.

Available in Portable Document Format (PDF) from the [American Academy
of Ophthalmology (AAO) Web
site](http://www.aao.org/education/guidelines/benchmarks/index.cfm).

Print copies: Available from American Academy of Ophthalmology, P.O. Box
7424, San Francisco, CA 94120-7424; telephone, (415) 561-8540.

#### PATIENT RESOURCES

The following patient education booklet is available:

-   Diabetic retinopathy (2001)

The following patient education brochure is available:

-   Diabetic retinopathy (1998)

-   Diabetic Retinopathy (Spanish: Retinopatia Diabetica) (1998).

The following patient education videotape is available:

-   Diabetic retinopathy (1990)

Print copies: Available from the American Academy of Ophthalmology
(AAO), P.O. Box 7424, San Francisco, CA 94120-7424; Phone: (415)
561-8540.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on February 20, 1999. The information
was verified by the guideline developer on April 23, 1999. This summary
was updated again on April 30, 2004. The information was verified by the
guideline developer May 20, 2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Information about the
content, ordering, and copyright permissions can be obtained by calling
the American Academy of Ophthalmology at (415) 561-8500.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008