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Diabetic retinopathy is a vascular disease of the retina that is usually asymptomatic in the early stages but can lead to visual impairment and blindness as the disease progresses. The majority of cases of diabetic retinopathy are detected during screening examinations. Further tests ( , ) may be performed to determine severity or identify complications. Management for all patients includes optimization of treatment for diabetes, managing risk factors for atherosclerotic cardiovascular disease (ASCVD), and referral to an ophthalmologist for further management and monitoring. Further treatment depends on the subtype (nonproliferative diabetic retinopathy or proliferative diabetic retinopathy), presence of macular edema, and severity of diabetic retinopathy and includes panretinal photocoagulation (PRP), intravitreal anti-vascular endothelial growth factor (VEGF) and vitrectomy.
Overview of diabetic retinopathy
|Overview of diabetic retinopathies |
|Nonproliferative retinopathy (NPDR)||Proliferative retinopathy (PDR)||Diabetic macular edema (DME)|
|Examination findings (dilated comprehensive eye exam or retinal photography)|
|Vision loss|| || |
- After 15 years, approx. 80% of patients with type 1 diabetes will develop retinopathy. 
- Among patients > 30 years old with type 2 diabetes: 
- Diabetic retinopathy is the most common cause of visual impairment and blindness in patients aged 20–74 years. 
Epidemiological data refers to the US, unless otherwise specified.
- Early stages: usually asymptomatic 
- Patients may experience symptoms of associated complications, e.g., macular edema, vitreous hemorrhage, and retinal detachment. 
- Later stages: significant visual impairment progressing to blindness
- Dilated comprehensive eye examination performed by an ophthalmologist/optometrist
- Retinal photography
- Interval: every year 
Less frequent retinopathy screening (e.g., every 2 years) may be considered in consultation with an ophthalmologist or optometrist for patients with diabetes who have a normal initial eye exam and good glycemic control. 
General principles 
- Usually detected on screening
- Symptomatic patients should undergo a slit lamp examination and fundoscopy) with the pupil dilated. (including
- Ancillary testing, e.g., OCT), , may be performed to:
- Assess disease severity.
- Determine treatment approach and assess response.
- Exclude differential diagnoses of sudden vision loss.
|Findings in diabetic retinopathy |
|NPDR||Mild NPDR|| |
|Clinically significant macular edema|| |
- Refer all patients with diabetic retinopathy to an ophthalmologist.
- Optimize glycemic control with: 
- Manage ASCVD risk factors.
- because of the high risk of co-occurrence.
- Arrange follow-up eye exams at regular intervals. 
- For patients with significant vision impairment, consider:
Early detection and treatment of diabetic retinopathy can prevent 90% of blindness. 
Treatment by retinopathy subtype 
- Nonproliferative retinopathy
Proliferative retinopathy: PRP and/or anti-VEGF therapy
- Both PRP and anti-VEGF therapy are equally effective.
- PRP is usually preferred as treatment occurs in a single session (reduces risk of loss to follow-up). 
- Anti-VEGF injections alone can be considered for patients who are highly motivated and have no .
- Additional treatments should be utilized if after initial treatment, any of the following are present:
- Macular edema 
- Refractory disease or severe complications (e.g., tractional retinal detachment, vitreal hemorrhage): Consider vitrectomy.
- Optimize to ensure patients meet . 
- Manage . 
- Educate patients on the importance of
- Ensure patients are aware that they may not experience symptoms until the disease is advanced.
- Address Managing chronic conditions”). (see “
- Advise patients to seek immediate medical attention if they notice any changes in their vision.
Advise patients to attend regular screenings as microvascular complications are usually asymptomatic until significant damage has occurred. 
Special patient groups
Diabetic retinopathy in pregnancy 
- Pregnancy can precipitate or aggravate diabetic retinopathy in patients with type 1 DM and type 2 DM.
- Diagnostics and management of diabetic retinopathy are largely the same as for nonpregnant patients with the following changes: