The purpose of this chart review is to locate and document information in the medical record that indicates if an individual does or does not have diabetic retinopathy and/or macular edema. The primary goal of this chart review is not to collect a large amount of data, but to confirm if the individual should be considered a case, control, or if a determination cannot be made.
Important information about dates
For chart abstractions done on this study, the most recent date you should look at in the medical record is ___/___/_____. If a patient has a relevant diagnosis after this date, you should ignore it. Since the patient’s medical status is changing, using a static reference date saves us from having to review charts again to see if anything new has been added.
1. Patient has a confirmed diagnosis of diabetic retinopathy or macular edema
The following diagnoses (including ICD9 codes) are used to specify if a subject has diabetic retinopathy or macular edema. Along with each specific diagnosis that could be used, a separate “Group” has been added, which is how diabetic retionpathy and macular edema are being categorized in this study. You will need to specify the first positive mention of a diagnosis for a particular group. Note that you will need to identify which eye the diagnosis was made for – if it is unspecified anywhere in the record, you should indicate “Unknown”.
The abbreviations used in ophthalmology for the location include:
OD = right eye
OS = left eye
OU = both eyes
Initial diagnoses will most commonly be made by a physician in an ophthalmology department, but may be indicated in other clinical notes if a diagnosis was made outside of the institution. It is important that the diagnosis be for diabetic retinopathy or macular edema. Since other non-diabetic types exist, you must ensure the distinction is made in the note.
In addition, some procedures are performed for diabetic retinopathy or macular edema. These procedures will be performed by a physician in an ophthalmology department, but may be indicated in other clinical notes if the procedure was performed at another institution. Consent forms for laser treatment may also indicate a procedure took place.
A procedure alone does not indicate a diagnosis of diabetic retinopathy or macular edema, but if one of the procedures below is indicated you may need to look before or after the procedure note to see if a procedure was performed for diabetic retinopathy or macular edema and was just not formally diagnosed within the institution. This could happen if a patient was referred in for the procedure, but receives care elsewhere.
Impltj Intravitreal Drug Dlvr Sys Rmvl Vts
Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous
Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping
Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation
Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation
Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker)
Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique
Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens
Dstrj Loclzd Les Retina 1+ Sess Crtx Dthrm
Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; cryotherapy, diathermy
2. Patient had a dilated eye exam within the past 2 years
Starting with the most recent, look at all ophthalmology and optometry documentation for the past 2 years prior to the reference date (listed at the top of the code book). If a patient is deceased, look at the past 2 years prior to their date of death. If the patient had an eye exam performed and the documentation indicates that the patient was dilated, mark this as “Yes”. If there is an eye exam but you cannot determine if the patient was dilated or not, the exam does not count.
If it doesn’t explicitly say that the patient’s eyes were dilated, there are other ways that the use of the dilation drops are documented. This includes:
Phenyothine Hydrochlroide 2.5
3. Last eye exam has indications of diabetic retinopathy or macular edema
For the last dilated eye exam found in question 2, look for any indication that the patient had or might have diabetic retinopathy or macular edema.
For initial patients (consults, new patients) and for some established patients, the forms will have a specific area for “Pupils” where the assessment is documented. If the pupils are clear, and there is no indication of diabetic retinopathy or macular edema, there will be a notation of “PERRLA” (pupils equal, round, reactive to light and accomodation) or “- APD” (the “-“ means negative, so also look for a neagative indication such as the terms “neg” or “negative” or “no”). If there is a pupil abnormality, you will see a positive indication of APD (afferent puil defect) documented as “APD” and may have a numeric grade such as “+1 APD” or “2+ APD”.
Note that some forms do not have a designated location for an assessment of the pupils. The nomenclature of PERRLA and APD are still used, but will require you to look at the entire form. Additional abbreviations, acronyms and terms that would indicate possible diabetic retinopathy or macular edema are listed below.
NVD – neovascularization of the disc (creation of new blood vessels)
NVE – neovascularization of the retina elsewhere (outside the disc)
PPDR – pre-proliferative diabetic retinopathy
BDR – background diabetic retinopathy
4. Additional comments/notes
Please use this area for any additional notes that you might want to make for yourself, or questions that need to be raised for a re-review. This can be filled at any time during the chart review.
5. Review Completed
This is an optional field that you may use to mark this chart review as completed when you feel you have reviewed all of the relevant information in the medical record. This does not need to be filled in if you choose to use some other mechanism (i.e. special folder for completed review forms) to manage the review.