Exhibit 7
Notification Procedures for Lesions of Hypertension and Diabetes
| Grading Item | Letter? | Suggested language | Referral to ophthalmologist? |
| Focal narrowing | No letter | ||
| Sheathing | No letter Exception: if sheathing is associated with an occlusive process, please see letter recommendations under Other/ Occlusions. |
||
| AV nicking | No letter | ||
| Ma | Routine notification for definite appearance No letter for questionable appearances |
". . . exhibits a single retinal microaneurysm. This could be due to diabetes, hypertension, or some other cause, and may be of little clinical significance." | None Information may be of interest to primary care physician. |
| RH | Routine notification for definite appearance No letter for questionable appearances |
". . . exhibits a single retinal hemorrhage. This could be due to hypertension, diabetes, or some other cause, and may be of little clinical significance." | None Information may be of interest to primary care physician. |
| H/Ma | Routine notification. If definite H/Ma is present, but identity as Ma or RH is in doubt, send letter. |
". . . exhibits a small red spot [or spots] which could be either retinal hemorrhage or a retinal microaneurysm[s]. This [these] could be due to diabetes, hypertension or some other cause, and may be of little clinical significance." | None Information may be of interest to primary care physician. |
| SE | Routine notification for definite appearance No letter for questionable appearances |
". . . exhibits a single soft exudate, or cotton-wool spot. This could be due to hypertension, diabetes, or some other cause, and may be of little clinical significance." | None Information may be of interest to primary care physician. |
| CSME | Routine notification for questionable CSME
Retinal alert for definite CSME |
". . . exhibits [description of definite
lesions]. These lesions are typical of [appropriate descriptive phrase for diabetic
retinal level]. Based on the proximity of the hard exudates to the macula [or other
suggestive appearances] . . ." Similar to above. |
". . . routine observation by an
ophthalmologist may be advisable." Time frame for referral per Retinal Reading Center ophthalmologist. ". . . observation by an ophthalmologist within the next __ months may be advisable." |
| [Other lesions of diabetic retinopathy] | Please see letter recommendations for appropriate diabetic retinal level . | ||
| Laser PC scars |
Routine notification.
Consult Retinal Reading Center ophthalmologist for possible retinal alert if diabetic retinopathy > DR level 65 persists. |
". . . exhibits [description of definite
lesions]. These lesions are characteristic of [appropriate descriptive phrase for diabetic
retinal level]. The presence of photocoagulation treatment scars suggests that the
participant has been under an ophthalmologist's care." Language as suggested by the Retinal Reading Center ophthalmologist. |
None, if no lesions are seen. "Continued follow-up by an ophthalmologist may be advisable." if diabetic retinopathy is present. Referral as suggested by Reading Center ophthalmologist. |
| Papillary swelling | No letter for: Q papillary swelling, nerve head drusen. Consult Retinal Reading Center ophthalmologist for cases where grader is unsure of cause or significance. Retinal alert for papillary swelling with associated retinal hemorrhages and/or soft exudates, suggesting severe hypertensive retinopathy. |
Language as suggested by the Retinal
Reading Center ophthalmologist. Language as suggested by the Retinal Reading Center ophthalmologist. |
Referral as suggested by Reading Center ophthalmologist. Time frame as suggested by Reading Center ophthalmologist. |
| DR 14 | Routine notification | ". . . exhibits a single soft exudate, or cotton-wool spot [IRMA, hard exudate]. This could be due to hypertension, diabetes, or some other cause, and may be of little clinical significance." | None Information may be of interest to primary care physician. |
| DR 15 | Routine notification | ". . . exhibits a single retinal hemorrhage. This could be due to hypertension, diabetes, or some other cause, and may be of little clinical significance." | None Information may be of interest to primary care physician. |
| DR 20 | Routine notification | 1 Ma: ". . .exhibits a single retinal
microaneurysm. This could be due to diabetes, hypertension or some other cause, and may be
of little clinical significance." > 2 Ma's: ". . . exhibits several [or provide the number] retinal microaneurysms. These are typical of very early diabetic retinopathy, but could be due to hypertension or some other cause." |
None Information may be of interest to primary care physician. |
| DR 35 | Routine notification
Exceptions: 1) if questionable CSME is present, or if HE is within 2 DD of center
2) if the macula is ungradable
3) if definite CSME is present (retinal alert) |
". . . exhibits retinal hemorrhages and
microaneurysms, and soft exudates (cotton-wool spots). These lesions are typical of early
diabetic retinopathy."
". . . exhibits retinal hemorrhagesand microaneurysms, and hard exudates (lipid deposits). These are typical of early diabetic retinopathy. Based on the proximity of the hard exudates to the macula, . . ." ". . . exhibits [describe lesions]. These are typical of early diabetic retinopathy. We are unable to evaluate the macula because of a dark shadow [or other impairment]." Language as suggested by Reading Center ophthalmologist. |
None Information may be of interest to primary care physician.
". . . routine observation by an ophthalmologist may be advisable."
"Routine observation by an ophthalmologist may be advisable."
Time frame as suggested by Reading Center ophthalmologist. |
| DR 43 | Routine notification
Exceptions: 1) if definite CSME is present.
2) if photocoagulation scars are present. |
". . . exhibits moderate amounts of
retinal hemorrhage and microaneurysms, [describe other lesions]." OR ". . .
exhibits [describe other lesions] and IRMA (intraretinal microvascular
abnormalities)." "These are typical of moderate non-proliferative diabetic
retinopathy."
Language as suggested by Reading Center ophthalmologist.
" The presence of photocoagulation treatment scars suggests that the participant has been under an ophthalmologist's care." |
"Routine observation by an
ophthalmologist may be advisable."
Referral as suggested by Reading Center ophthalmologist. "Continued follow-up by an ophthalmologist may be advisable." |
| DR 47 | Routine notification
Exceptions: 1) if definite CSME is present.
2) if photocoagulation scars are present. |
". . . exhibits moderate amounts of
retinal hemorrhage and microaneurysms, [describe other lesions] and IRMA (intraretinal
microvascular abnormalities). These are typical of moderate non-proliferative diabetic
retinopathy."
Language as suggested by Reading Center ophthalmologist.
" The presence of photocoagulation treatment scars suggests that the participant has been under an ophthalmologist's care." |
"Routine observation by an
ophthalmologist may be advisable."
Referral as suggested by Reading Center ophthalmologist. "Continued follow-up by an ophthalmologist may be advisable." |
| DR 53 | Retinal alert | ". . . exhibits [describe lesions]. These lesions are typical of severe non-proliferative diabetic retinopathy." | Time frame as suggested by Reading Center ophthalmologist. |
| DR 61 | Routine notification if scatter
photocoagulation treatment scars are present.
Retinal alert if untreated. Consult the Retinal Reading Center ophthalmologist. |
". . . exhibits [description of definite
lesions]. These lesions are characteristic of proliferative diabetic retinopathy. The
presence of photocoagulation treatment scars suggests that the participant has been under
an ophthalmologist's care." Language as suggested by Reading Center ophthalmologist. |
"Continued follow-up by an
ophthalmologist may be advisable."
Time frame as suggested by Reading Center ophthalmologist. |
| DR 65 DR 71 DR 75 DR 81 DR 85 |
Retinal alert. Consult the Retinal Reading Center ophthalmologist. | Language as suggested by Reading Center ophthalmologist. | Time frame as suggested by Reading Center ophthalmologist. |
| DR 90 | No letter if no lesions are seen. Check
"ungradable for notification conditions" for the Retinal Notification Sent item. Routine notification if lesions such as retinal hemorrhage or soft exudate are seen, but other lesions are ungradable.
Consult Retinal Reading Center ophthalmologist for cases where grader is unsure of significance of visible lesions. Retinal alert if time frame for referral is provided. |
". . . exhibits retinal hemorrhage [or whatever lesions are visible]. The photographic quality is impaired by a dark shadow over the macula [or whatever impairment is present], and we may be unable to evaluate some other lesions of diabetic retinopathy."
Language as suggested by Reading Center ophthalmologist. |
"Routine observation by an ophthalmologist may be advisable."
Routine observation or time frame for referral, as suggested by Reading Center ophthalmologist. |
Return to Light Box Grading Protocol
2/17/98