regression was noted. In interpreting these studies and their clinical implications21, it must be noted that DR was not the primary endpoint by design, a tertiary endpoint in FIELD, and DR endpoints recorded in a sub study cohort of the ACCORD study population. Hence, the exact beneficial action of fenofibrate on DR remains to be elucidated. Recommendations for lipid management in diabetes · Consider statins in secondary prevention of macrovascular disease as well as in primary prevention. (Level A) · Avoid statins in pregnancy (Level A) · Consider Ezetimibe for patients intolerant of statins. · Consider adding fenofibrate to a statin for non-proliferative retinopathy in type 2 diabetes. (Level B) 6.2.4 Smoking Although smoking contributes to the development but not progression of nephropathy in Type 1 diabetes, no clear association of smoking and retinopathy has been demonstrated. Smoking may be important in some patients with Type 1 diabetes as current smoking has been shown to be associated with microangiopathy when complications occur early in the course of type 1 diabetes22. In a specific study of smoking a univariate analyses showed a significant association of pack-years and progression to proliferative diabetic retinopathy in older-onset subjects on insulin23 . After controlling for known risk factors for the incidence and progression of retinopathy, pack-years smoked was borderline significant in predicting incidence of retinopathy in younger-onset subjects. Smoking was not associated with incidence in older-onset subjects or with progression or progression to proliferative diabetic retinopathy in any of the groups (Level 2). Counselling and treatment for smoking is cost effective in diabetes management24 (Level 1). Guidelines for patients with diabetes who smoke 47 · Patients with DR should be made aware that they are at higher risk of cardiovascular disease ( Level A) · All smokers should be encouraged to quit as part of healthy life-style advice. (Level A) 6.3 INTERACTIONS OF RISK FACTORS FOR DIABETC COMPLICATIONS The interaction of different risk factors has been well documented in two long-term studies of patient with Type 2 diabetes. In the UKPDS, the risk of complications was associated independently and additively with hyperglycaemia and hypertension with risk reductions of 21% per 1% HbA1c decrement and 11% per 10 mmHg systolic blood pressure decrement 25(Level 1). In another smaller study of Type 2 diabetes over a period of 7.8 years intensified, multi-targeted medical treatment aiming for HbA1c < 6.5%, fasting serum total cholesterol level SECTION 7: CLINICAL FEATURES OF DIABETIC RETINOPATHY 7.1 INTRODUCTION Diabetic retinopathy (DR) is essentially, but not exclusively, a microvascular disease. Individual DR features helps the clinician to evaluate the risk of imminent visual impairment ( e.g. subfoveal macular oedema, new vessels) as well as that of significant future risk (e.g.extra/juxtafoveal macular oedema, surrogate markers of capillary non-perfusion or leakage), thus assisting in developing a management plan for an individual patient. The classification of diabetic retinopathy has a dichotomous approach- the presence or absence of new vessels, the presence or absence of subfoveal macular oedema. Yet in spite of its importance, the pathogenesis of many retinopathy features is not fully understood.Much of our knowledge about individual features has come from studying fluorescein angiography of the retinal circulation. The role of the retinal pigment epithelium and choroidal circulation in diabetic retinopathy is largely unknown. Since the previous edition of the RCOphth diabetic retinopathy guidelines, both population based digital image photographic DR screening programmes and optical coherence tomography have become established throughout the United Kingdom. 7.1.1 Traditionally, for ophthalmologists the term maculopathy has meant the presence of exudates, haemorrhages or retinal thickening, within a two disc diameter radius centred on the fovea - in isolation or in conjunction with one another. This terminology requires updating- optical coherence tomography may show intra-retinal fluid in the absence of retinal thickening and there is added confusion with screening programmes using a different terminology for maculopathy. 7.1.2 To avoid confusion, this guideline recommends that the term maculopathy is used in the context of the diabetic retinopathy screening programme (UK)., while for clinical use more specific descriptions of the features of clinically significant maculopathy such as macular oedema (centre involving or otherwise), exudation with or without thickening, and ischaemia. (See section 11) 7.2 FEATURES OF NON-PROLIFERATIVE DIABETIC RETINOPATHY Recognising features of non-proliferative retinopathy enables to predict an individual’s risk of future new vessel formation, and to recommend a safe review interval. The importance of localising macular changes in the non-proliferative stage of retinopathy is to ascertain risk to the fovea (and vision) of macular oedema and lipid deposition. The first clinical signs of diabetic retinopathy are a consequence of isolated capillary occlusion (reference) with adjacent non-occluded capillaries forming saccular or fusiform swellings called microaneurysms. The capillary circulation is only visible on fluorescein angiography. 56 7.2.1 Microaneurysms These appear as isolated, spherical, red dots of varying size. There are a number of theories to explain their presence- they may reflect an abortive attempt to form a new vessel or may simply be a weakness of capillary vessel wall through loss of normal structural integrity. Individual microaneurysms may leak resulting in dot haemorrhage, oedema and exudate. Spontaneous thrombosis may lead to resorption of haemorrhage oedema and exudate. The thrombosed microaneurysm usually disappears from clinical view, but occasionally remains visible as a white dot. 7.2.2 Dot Haemorrhages Dot haemorrhages cannot always be differentiated from microaneurysms as they are similar in appearance but with varying size. Hence it is traditional not to attempt differentiate them on clinical