Clinical guidelines for diabetic retinopathy in Kenya: an executive summary of the recommendations

Abstract

All persons living with Diabetes Mellitus (DM) have a lifetime risk of developing Diabetic Retinopathy (DR), a potentially blinding microvascular complication of DM. The risk increases with the duration of diabetes. The onset and progression of DR can be delayed through optimization of control of blood glucose, blood pressure and lipids. The risk of blindness from DR can be reduced through cost-effective interventions such as screening for DR and treatment of sight-threatening DR with laser photocoagulation and anti-VEGF medications. Several factors make it important to provide guidance to clinicians who provide services for diabetes and diabetic retinopathy in Kenya. First, the magnitude of both DM and DR is expected to increase over the next decade. Secondly, as the retina is easily accessible for examination, the early signs of retinopathy may provide clinicians with the first evidence of microvascular damage from diabetes. This information can be used to guide subsequent management of both DM and DR. Thirdly, there are notable gaps in service delivery for the detection, treatment and follow-up of patients with DR, and the services are inequitable. Strengthening of service delivery will require close collaboration between diabetes services and eye care services. Following a systematic and collaborative process of guideline development, the first published national guidelines for the management of diabetic retinopathy have been developed. The purpose of this paper is to highlight the recommendations in the guidelines, and to facilitate their adoption and implementation.

Full text

33
Journal of Ophthalmology of Eastern Central and Southern AfricaDecember 2017
Clinical guidelines for diabetic retinopathy in Kenya: an executive summary of the
recommendations
Nyawira M1,9 , Muchai G2,4, Gichangi M3, Gichuhi S2, Githeko K4, Atieno J5, Karimurio J2, Kibachio J6, Ngugi N7,
Nyaga P7, Nyamori J2, Zindamoyen ANM8, Bascaran C9, Foster A9 for the Technical Working Group
1Kenya Medical Training College, Nairobi, Kenya
2Department of Ophthalmology, University of Nairobi, Kenya
3Ophthalmic Services Unit, Ministry of Health, Kenya
4Upper Hill Eye and Laser Center, Kenya
5Kabarak University, Nakuru, Kenya
6Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
7Kenyatta National Hospital, Nairobi, Kenya
8PCEA Kikuyu Eye Hospital, Kikuyu, Kenya
9London School of Hygiene and Tropical Medicine, London, United Kingdom
Corresponding author: Dr Nyawira Mwangi, Kenya Medical Training College, Nairobi, Kenya. Email: Nyawira.
Mwangi@lshtm.ac.uk
ABSTRACT
All persons living with Diabetes Mellitus (DM) have a lifetime risk of developing Diabetic Retinopathy (DR), a
potentially blinding microvascular complication of DM. The risk increases with the duration of diabetes. The
onset and progression of DR can be delayed through optimization of control of blood glucose, blood pressure
and lipids. The risk of blindness from DR can be reduced through cost-eective interventions such as screening
for DR and treatment of sight-threatening DR with laser photocoagulation and anti-VEGF medications.
Several factors make it important to provide guidance to clinicians who provide services for diabetes and
diabetic retinopathy in Kenya. First, the magnitude of both DM and DR is expected to increase over the next
decade. Secondly, as the retina is easily accessible for examination, the early signs of retinopathy may provide
clinicians with the rst evidence of microvascular damage from diabetes. This information can be used to guide
subsequent management of both DM and DR. Thirdly, there are notable gaps in service delivery for the detection,
treatment and follow-up of patients with DR, and the services are inequitable. Strengthening of service delivery
will require close collaboration between diabetes services and eye care services.
Following a systematic and collaborative process of guideline development, the rst published national
guidelines for the management of diabetic retinopathy have been developed. The purpose of this paper is to
highlight the recommendations in the guidelines, and to facilitate their adoption and implementation.
Key words: Clinical practice guidelines, Diabetic retinopathy, Kenya
INTRODUCTION
Diabetes Mellitus (DM) is a priority non-communicable
disease that requires multidisciplinary care and continuity
of care. Its prevalence and incidence is increasing in
every country. According to the STEPwise survey1 for
risk factors of non-communicable diseases in 2015, DM
affects an estimated 2% of the Kenyan population aged
18-69 years with the highest proportion (5%) being in
the 45-59 years age group. Every patient with diabetes
is at risk of potentially blinding ocular complications,
particularly Diabetic Retinopathy (DR). In turn, visual
loss from diabetic retinopathy is associated with additional
morbidity, such as falls, fractures and difculties with
seeing and taking medications. Both DM and DR are
silent diseases that patients may be unaware of until they
cause complications. Clinicians attending to patients
with these conditions have a role to reduce the associated
morbidity, disability and mortality.
Diabetic Retinopathy (DR) is the leading cause of
blindness in diabetes, and for this reason it warrants
specic attention. It is estimated that a third of the
people with diabetes have diabetic retinopathy, and one
third of the latter (or 10% of those with diabetes) have
vision threatening DR2. Early signs of retinopathy
or maculopathy in a patient with diabetes, identied
on retinal examination, may be the rst evidence of
generalised microvascular damage from poor control
of diabetes. This information would be very useful in
planning subsequent holistic management of the patient.
There is therefore need to strengthen links between eye
care services and diabetes services.

34
Journal of Ophthalmology of Eastern Central and Southern Africa December 2017
The risk factors for DR include both modiable and
non-modiable factors. Epidemiologic studies have
identied the non-modiable risk factors to include
increasing duration of diabetes and genetic factors2,3.
The leading modiable risk factors include poor
control of blood sugar, poor control of blood pressure
and dyslipidaemia2,4-6. Service providers need to pay
attention to these factors, as well as to other lifestyle
factors associated with diabetes in order to delay onset or
progression of DR. These are interventions for primary
prevention of blindness from DR.
Stronger service delivery for DR is required within the
existing health system7-9. Currently there are notable gaps
in the screening, diagnosis, referral, treatment and follow-
up. Although screening for DR and laser treatment are
cost-effective interventions for prevention of blindness
from DR10, there are inequities in access to them. Some
of the services are underutilised and of insufcient
quality. DR guidelines and use of clinical guidelines is
an important step towards ensuring that all people with
diabetes have access to quality DR services.
The purpose of these clinical practice guidelines is
to give guidance regarding screening and diagnosis of
DR, management of diabetes as it pertains specically to
DR, and treatment of DR. These guidelines apply to all
patients with type 1 or type 2 diabetes who are at least 12
years old, who receive care at the primary, secondary or
tertiary level of the health system. They should be used by
health workers providing diabetes services and eye care
services, as well as by administrators and policy-makers
who plan for the resources for these services.
METHODOLOGY FOR GUIDELINES
DEVELOPMENT
The development of these guidelines was a systematic,
widely consultative process guided by an expert
technical group over a lengthy period and involving
many stakeholders. The process was guided by the use of
several toolkits and guidelines which include: ADAPTE
toolkit11, PGEAC framework12, AGREE 11 instrument13
and WHO handbook for guidelines development14.
The guidelines were adapted from existing relevant
standards and guidelines, particularly the American
Diabetes Association standards for medical care in
diabetes15 International Council of Ophthalmology
guidelines for diabetic eye care16 Canadian Diabetes
Association’s retinopathy guidelines17 and the Royal
College of Ophthalmologists’ diabetic retinopathy
guidelines18. The following guidelines were also
reviewed, and the recommendations are in line with their
provisions: Kenya national guidelines for management
of diabetes19, Kenya national strategy for the prevention
and control of non-communicable diseases20, and
International Diabetes Federation’s diabetes eye health
guide for health professionals21. The adaptation strategy
was chosen instead of de novo development in order to
avoid duplication of effort, to use the available resources
cost-effectively and to facilitate customization of the
guidelines to reect local context. These guidelines
were identied through a literature search followed by
application of the AGREE 11 instrument to evaluate the
quality of the guidelines. Previous drafts of local DR
guidelines were also reviewed. Care was taken to ensure
that the guidelines are evidence-based, locally applicable,
of high quality, and that the process of adaptation was
consultative. The guidelines were subjected to external
review by a multidisciplinary team as well as pilot-testing
in various health facilities.
The process of guideline development is discussed in
detail in a separate paper.
Key messages
1. Stronger service delivery is needed for People
Living with Diabetes (PLWD) in Kenya in relation
to DR. There is need to develop strong links between
diabetes services and eye care services within the
existing health system.
2. Blindness from DR is avoidable, but only if diabetes
care givers and eye health professionals perform
their roles in ensuring early detection and treatment
of DR.
3. Screening is important for early detection of treatable
diabetic retinopathy. It is also a cost-effective
intervention for reducing blindness from DR. All
patients with diabetes aged 12 years and above
should have a retinal examination (usually a dilated
eye examination or a retinal photograph) once a
year or more frequently if recommended by the eye
specialist.
4. Consistent and appropriate metabolic control reduces
the onset and progression of sight-threatening
diabetic retinopathy.
5. Laser photocoagulation therapy, local intraocular
pharmacological therapy and surgery reduce the risk
of signicant visual loss.
Recommendations
Domain: Strengthening links between diabetes services
and eye care services at primary, secondary and tertiary
level of care
1. All health workers providing diabetes services should
raise awareness of PLWD on diabetic retinopathy and
support them to access eye examination (Panel 1).
2. The health worker attending to a PLWD at any health
care level should use a checklist (Panel 2) to identify
whether the patient has had a retinal examination in
the preceding 12 months. Any patient who has not
should be referred to the nearest facility for screening
for DR.

35
Journal of Ophthalmology of Eastern Central and Southern AfricaDecember 2017
3. The screening examination for DR should be
performed by trained personnel (health care worker,
eye care workers or technicians) and should consist
of a minimum of:
a. A retinal examination appropriate for DR,
which would include dilated direct or indirect
ophthalmoscopy, slit lamp bio-microscopic
examination of the retina or retinal photography.
b. Visual acuity test using distant and near charts.
If the visual acuity is reduced, then pin hole test
is also performed.”
4. All PLWD require follow up, therefore service
providers in both eye clinics and diabetes clinics
should encourage compliance with follow-up.
5. A service charter for diabetes services and eye care
services should be available in all clinics offering
these services to inform PLWD of the minimum care
they should expect and to highlight the importance
of yearly comprehensive risk assessment including
dilated eye examination.
6. The ophthalmologist and the physician/diabetologist/
endocrinologist will provide clinical governance as
the team leads for diabetes services and eye care
services. The clinical governance team would also
include: (a) liaison diabetes nurse (from the diabetes
clinic), (b) liaison ophthalmic nurse (from the eye
clinic), (c) designated medical records ofcer and (d)
a biomedical / equipment maintenance technician.
7. The physician/diabetologist/endocrinologist and the
ophthalmologist would be responsible for oversight
on the screening for DR, training of health workers
and data management.
8. The Ophthalmic Services Unit would be responsible
for clinical governance for DR services at national
level.
9. Data would be systematically collected in both
diabetes clinics and eye clinics. The liaison nurse in
the diabetic clinic and eye clinic would forward the
captured data to the designated records ofcer for
reporting.
10. The Ophthalmic Services Unit would coordinate
the use of this data to inform decisions on service
improvement strategies.
Panel 1: Key messages for health workers attending to
PLWD
1 in 3 of patients with diabetes has diabetic retinopathy.
Act to save their vision today!
1Send all newly diagnosed patients with diabetes
for a baseline retinal examination.
2Ensure all patients with diabetes have an annual
retinal examination.
3Refer any patient with diabetes who has poor
vision to an eye specialist urgently.
4Do not wait for visual loss to refer patients with
diabetes to an eye specialist- ‘prevention is better
than cure.’
5Glycated hemoglobin (HbA1c) is a good indicator
for long-term sugar control and should be done
at least annually for all patients. Good glycemic
control prevents or delays diabetic retinopathy.
6Assess for other end organ damage- oral
examination, diabetic foot review, renal and
cardiac function, tests for neuropathy at least
annually
7Assess for hypertension, hyperlipidemia and other
co-morbidities as these may impact negatively on
diabetes and diabetic retinopathy.
8Send all pregnant patients with diabetes for a
retinal examination at least each trimester and
post-delivery, or more frequently if recommended
by the eye specialist.
Panel 2: Checklist for screening for DR
Patients name: …………………………………………
Date of birth: …………………………………………
Date of screening: ……………………………………
Duration of diabetes: …………………………………
Have you ever had an examination of the back of the eye
(either a photograph was taken or drops were instilled
into the eye before examination)?
a. YES b. NO
How long ago was the last examination of the back of the
eye?
a. < 12 months b. ≥ 12 months
Where was the eye examination done? ...........................
facility
Recommendation: ……………………………………
Have an eye check: as soon as possible / in the next
………………. months at………………. health facility
Domain: Eye examination for DR
Annual dilated and comprehensive eye examination is
recommended for all patients with diabetes, aged 12 years
and above, starting at the time of diagnosis of diabetes
mellitus, unless the eye specialist recommends a different
frequency. For type 1 diabetes, an eye exam should be
done at diagnosis, at 5 years of diagnosis and annually
thereafter.

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Journal of Ophthalmology of Eastern Central and Southern Africa December 2017
Domain: Patient-centred care
1. Health workers should provide verbal and written
information on diabetes, diabetic retinopathy, and
on the health care that is needed, including self-
management.
2. All PLWD should receive regular and individualised
self-management support on healthy diet, appropriate
physical activity and weight reduction if they are
overweight. All smokers should be encouraged to
quit smoking.
3. Patient education materials such as posters, leaets,
booklets and yers on DR should be available (Panel
3) to patients and to peer support groups.
4. Diabetes support and structured self-management
education should also be provided to family members
of PLWD.
5. PLWD should be treated with dignity and involved
in decision-making for their care. The results of
their examination and the implications should be
explained to them, and they should be encouraged to
ask questions. The presence of co-morbidities should
be taken into consideration in the care of each patient.
Panel 3: Key messages for patients
DID YOU KNOW THAT DIABETES AFFECTS THE
EYES?
What can you do to prevent blindness?
1Diabetes mellitus is marked by high sugar levels
in blood. High blood sugar destroys small blood
vessels in the body including those at the back
of the eyes, leading to a condition called diabetic
retinopathy.
2Damage to the eyes is slow, painless, gets worse
with time and nally leads to blindness if not
treated in good time.
3The damage to the eyes needs to be detected early,
before permanent damage occurs.
4An eye check by an eye specialist can detect
damage to the eyes before symptoms develop.
During the examination, the eye specialist will
check vision, and instil an eye drop to assess the
damage in the eye. Both eyes need to be examined.
5For prevention and treatment of diabetic
retinopathy, the eye specialist may advise on sugar,
blood pressure, and lipid control.
6For treatment of diabetic retinopathy, the eye
specialist may perform laser or administer
injections in the eye or perform eye surgery.
7All persons with diabetes should have their eyes
checked once every year by an eye specialist, even
before any symptoms or poor vision develop or as
frequently as recommended by the eye specialist.
8A child with diabetes should have the eyes checked
annually from the age of 12 years, or more
frequently if recommended by the specialist.
9A pregnant mother with diabetes should undergo an
eye check by an eye specialist at least once every
trimester, and soon after delivery, or as frequently
as recommended by the eye specialist.
10 If the eyes are found to be normal at your eye
check by an eye specialist, please continue with an
eye check annually. If you notice any abnormality
with your eyes, visit the eye specialist as soon as
possible.
Domain: Metabolic control
1. All PLWD should be asked about the level of control
of glucose, blood pressure and lipids.
2. To prevent the onset and delay the progression of
diabetic retinopathy, people with diabetes should be
treated to achieve optimal control of blood glucose.
3. Regular monitoring of blood sugar at home should be
encouraged.
4. Regular monitoring of blood pressure in a health
care setting or at home should be encouraged. Target
blood pressure is 140/90 mmHg. Drugs blocking
the Renin-Angiotensin System (RAS) may have
benets, particularly for mild retinopathy, but should
be discontinued during pregnancy.
5. A comprehensive biochemical prole (risk
assessment) should be done at least annually,
and include fasting lipid prole, HbA1c, urine
microalbumin among other tests.
6. Aim for a target glycosylated haemoglobin (HbA1c)
of <7%.
7. Serum fasting lipid prole should be assessed at
diagnosis and annually. Consider statins in primary
and secondary prevention of DR but discontinue
statins in pregnancy.
Domain: Pregnancy
1. All female PLWD of reproductive age should be
asked if they are pregnant.
2. Patients should be assessed for diabetic retinopathy
before pregnancy, at least once every trimester of
pregnancy, as well as within 6 months after delivery
or more frequently if recommended by the eye
specialist.
3. Statins and angiotensin inhibitors should be
discontinued in patients who are planning for
pregnancy.
4. All women of child-bearing age who have diabetes
should be educated that pregnancies should be
planned.

37
Journal of Ophthalmology of Eastern Central and Southern AfricaDecember 2017
Domain: Screening programs for DR
1. All PLWD should be screened for DR at least once
a year, irrespective of whether they have ocular
symptoms or not.
2. Screening programs can utilise whatever screening
method is available (ophthalmoscopy, slit-lamp bio-
microscopy and retinal photography), and should be
conducted by a suitably trained person. Pupil dilation
is recommended. Visual acuity should be assessed
before pupil dilation.
3. Photography based screening
a. Where a fundus camera is available, ideally the
fundus camera should be located in the diabetes
clinic.
b. Fundus photographers should be trained to
identify cataract, other causes of media haziness
and glaucoma on the images. Patients who
have these pathologies should be referred to
an ophthalmologist. Ultrasonography may be
useful in assessing the posterior segment in the
presence of cataract or vitreous haemorrhage.
c. Regular retraining in form of short courses
(either online courses or standard contact
courses) should be provided for screeners.
4. The following patients should be referred to an
ophthalmologist:
a. Where the screening examination is unsuccessful,
or the results of the visual acuity test or retinal
examination are unclear
b. Where the retinal examination is unsuccessful,
for example due to additional pathologies
c. Any grade of retinopathy, except mild non-
proliferative retinopathy
d. Visual acuity worse than 6/12 and all patients
with ocular symptoms
5. Screening should identify true positives (patients
with DR). For this to be achieved, it is important to
use the correct equipment, adhere to the standards of
practice, make correct diagnosis and have a quality
assurance mechanism. The guidelines for quality
assurance are provided as an addendum to the
guidelines.
6. All health workers have a role in ensuring patients
undergo screening. All health workers should also
document and collect data on screening activities,
as the data is useful for planning and monitoring
services. Health workers at each health facility
will collect this data using standard monthly data
collection forms. The Ophthalmic Services Unit in
the Ministry of Health will coordinate the collection
of data.
Domain: Diagnostic evaluation of patients at the eye
clinic
Once the person with diabetes has been referred to
an eye specialist, he or she should undergo a complete
ophthalmic assessment. Ophthalmic evaluation by an
eye care worker is available at the secondary level of the
health system. This should include taking medical history,
assessing visual acuity, and identifying and grading DR
or Diabetic Macula Oedema (DME), using standard
procedures described in the guidelines.
Domain: Referral pathway
Once a decision for referral for evaluation or treatment has
been made, it should be carried out as soon as possible.
The nearest health facility offering DR services will be
identied (mapping of services has been conducted,
and this information is provided as an addendum to the
guidelines), and patients will be referred to reach the
facility on the designated days that the services can be
provided.
Domain: Treatment interventions
The ophthalmologist will make the nal diagnosis and
the decision on the treatment that the patient should
receive. There is evidence from Cochrane systematic
reviews included in Panel 4 to support the use of laser
photocoagulation in proliferative diabetic retinopathy22
anti-VEGF injections in diabetic macula oedema23 and
intravitreal steroids in refractory diabetic macula oedema24.
Laser or intravitreal injections can be administered by the
ophthalmologist at secondary level. Surgical interventions
for DR will be provided by the vitreo-retinal surgeon at
tertiary level. Practical information on these procedures is
provided in the guidelines.
Panel 4. Evidence from Cochrane systematic reviews for
Interventions used to treat diabetic retinopathy.
Laser photocoagulation is benecial in reducing the
risk of severe visual loss and the risk of progression
12 months after treatment in patients with proliferative
diabetic retinopathy compared to no treatment or deferred
treatment. However most trials here are old and the
quality of evidence is judged as low22.
There is very low or low quality evidence from randomized
controlled trials that anti-VEGF injections are effective in
patients with proliferative diabetic retinopathy but they
prevent intraocular bleeding25.
There is high quality evidence that anti-VEGF injections
are effective in preserving and improving vision in
patients with diabetic macula oedema compared to grid
laser23.

38
Journal of Ophthalmology of Eastern Central and Southern Africa December 2017
Intravitreal steroids delivered either by injection or
implants may improve visual outcomes in patients with
persistent or refractory diabetic macula oedema but it
is unclear whether they are benecial in other earlier
stages24.
Domain: Follow up
All PLWD screened for DR will require follow up. The
frequency of follow-up depends on the clinical ndings,
and the grading/severity of DR, as described in the
guidelines.
Domain: Patients with low vision
Refer the patient with low vision (best corrected visual
acuity of <6/18) for rehabilitation. PLWD who would
benet from counselling and social services should be
referred as appropriate.
Domain: Monitoring DR services
Specic process and outcome indicators will be used
to monitor services on a quarterly basis at each level of
service delivery, using the hospital health management
and information system. Health workers at each health
facility will therefore collect this data using standard
monthly data collection forms. The Ophthalmic Services
Unit will coordinate the collection of data. The indicators
of interest are listed in the guidelines.
CONCLUSIONS
Patients with diabetes require specic care relevant to
diabetic retinopathy, which includes patient education,
screening, referral, treatment and follow-up. These are
the rst published national clinical practice guidelines for
the screening and management of diabetic retinopathy.
Their goal is to ensure best practice throughout the
whole pathway from primary care to tertiary care.
Implementation of the guidelines has potential to reduce
blindness from DR.
The Working Group welcomes feedback from all users
of these guidelines. In particular, data on the enablers and
challenges experienced in the use of the guidelines would
be very useful in informing revisions on the guidelines.
Please email feedback to the Ophthalmic Services Unit,
Ministry of Health, through ophthalmicserviceske@
gmail.com.
ACKNOWLEDGEMENTS
We acknowledge The Fred Hollows Foundation for
funding the process of guidelines development.
Conict of interest: Nothing to declare.
REFERENCES
1. Ministry of Health, Kenya National Bureau of
Statistics, World Health Organization. Kenya
STEPwise survey for non-communicable diseases
risk factors 2015 report. Ministry of Health, Division
of Non-Communicable Diseases, 2015.
2. Yau JWY, Rogers SL, Kawasaki R, Lamoureux EL,
Kowalski JW, Bek T, et al. Global prevalence and
major risk factors of diabetic retinopathy. Diabetes
Care. 2012; 35:556-564.
3. University of Winsconsin. The Winsconsin
Epidemiologic Study of Diabetic Retinopathy
(WESDR) 2015 [cited 2015 151215]. Available
from: www.epi.ophth.wisc.edu.
4. The Diabetes Control and Complications Trial
Research Group. The effect of intensive treatment of
diabetes on the development and progression of long-
term complications on insulin-dependent diabetes
mellitus. New Engl J Med. 1993; 329(14):
5. King P, Peacock I, Donnelly R. The UK Prospective
Diabetes Study (UKPDS): clinical and therapeutic
implications for type 2 diabetes. Br J Clin Pharmacol.
1999; 48:643-648.
6. The ACCORD Study Group. Effects of intensive
blood-pressure control in type 2 diabetes mellitus.
New Engl J Med. 2010; 362:1575-585.
7. Poore S, Foster A, Zondervan M, Blanchet K.
Planning and developing services for diabetic
retinopathy in Sub-Saharan Africa. Int J Health
Policy Manag. 2015; 4(1):19-28.
8. Kupitz DG, Fenwick E, Kollmann KHM, Holz
FG, Finger RP. Diabetes and diabetic retinopathy
management in East Africa: Knowledge, Attitudes,
and Practices of hospital staff in Kenya. Asia-Pacic
Ophthalmol. 2014; 3(5):
9. Bastawrous A, Mathenge W, Wing K, Bastawrous M,
Rono H, Helen WA, et al. The incidence of diabetes
mellitus and diabetic retinopathy in a population-
based cohort study of people aged 50 years and over
in Nakuru , Kenya. 2017:1-14
10. Jones S, Edwards RT. Diabetic retinopathy screening:
a systematic review of the economic evidence.
Diabetic Med. 2010; 27(3):249-256.
11. The ADAPTE Collaboration. The ADAPTE process:
resource toolkit for guideline adaptation ver 2.0,
available at http://www.g-i-n.net. 2009.
12. Graham ID, Morrison MB. Evaluation and adaptation
of clinical practice guidelines. Evidence Based
Nursing (EBN). 2005; 8:68-72
13. The AGREE Research Trust. AGREE 11 instrument,
available at http://www.agreetrust.org. 2009.
14. World Health Organization. WHO Handbook for
guideline development, available at http://www.who.
int. 2012.

39
Journal of Ophthalmology of Eastern Central and Southern AfricaDecember 2017
15. American Diabetes Association. Standards of
Medical Care in Diabetes-2017. Diabetes Care.
2017; 40(Suppl 1):
16. International Council of Ophthalmology. ICO
Guidelines for Diabetic Eye Care-updated 2017.
San Francisco, California: International Council of
Ophthalmology, 2017 23 February 2017. Report No.
17. Canadian Diabetes Association Clinical Practice
Guideline Expert Committee, Boyd SR, Advani A,
Altomare F, Stockl F. Retinopathy. Can J Diabetes.
2013; 37 (Suppl 1):S137-41.
18. Royal College of Ophthalmologists. Diabetic
Retinopathy guidelines, available at www.rcophth.
ac.uk. 2012.
19. Ministry of Public Health and Sanitation. National
Clinical Guidelines for management of diabetes
mellitus. 2010.
20. Ministry of Health. Kenya National Strategy for
Prevention and Control of Non-communicable
Disease 2015-2020. 2015.
21. International Diabetes Federation, Foundation TFH.
Diabetes eye health: a guide for health professionals,
available at www.idf.org/eyecare. 2015.
22. Evans JR, Michelessi M, Virgili G. Laser
photocoagulation for proliferative diabetic
retinopathy. The Cochrane Database of Systematic
Reviews. 2014; 24(11):Cd011234.
23. Virgili G, Parravano M, Menchini F, Evans JR.
Anti-vascular endothelial growth factor for diabetic
macular oedema. Cochrane Database of Systematic
Reviews. 2014; (10)
24. Grover DA, Li T, Chong CCW. Intravitreal steroids
for macular edema in diabetes. Cochrane Database
of Systematic Reviews. 2008; (1)
25. Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I,
Pijoán JI, Buil-Calvo JA, Cordero JA, et al. Anti-
vascular endothelial growth factor for proliferative
diabetic retinopathy. Cochrane Database of
Systematic Reviews. 2014; (11)