Diabetic Retinopathy Management

Introduction to Diabetic Retinopathy

The American Diabetes Association recommends that a diabetic patient with blurry vision requires urgent dilated comprehensive eye examination by an ophthalmologist or optometrist to rule out sight-threatening diabetic retinopathy, macular edema, or other vision-threatening complications, while simultaneously optimizing glycemic control 1, 2
Urgent same-day referral is required if any visual symptoms are present in a patient with known diabetic retinopathy, or if the patient has had diabetes for >5 years (type 1) or any duration (type 2) without recent eye examination 1, 2, 3

Routine referral (within days to weeks) is recommended for new diagnosis of type 2 diabetes with blurry vision, or type 1 diabetes >5 years duration without recent screening 1, 3
The American Academy of Ophthalmology suggests that any level of macular edema, severe nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy requires prompt referral (Grade A recommendation) 1, 2

Intensive glycemic management is critical as it prevents and delays diabetic retinopathy progression and may improve visual function, with a strength of evidence level of A 6, 4, 2
Lowering blood pressure decreases retinopathy progression, with a strength of evidence level of A 1, 7
Fenofibrate may slow progression, particularly in mild nonproliferative diabetic retinopathy, with a strength of evidence level of B 7
Panretinal laser photocoagulation reduces severe vision loss from 15.9% to 6.4%, with a strength of evidence level of A 6, 1, 9
Anti-VEGF therapy (ranibizumab) is non-inferior to laser photocoagulation, with a strength of evidence level of A 1, 10, 9

Pregnant women with pre-existing diabetes require eye examination before pregnancy or in the first trimester, then every trimester and for 1 year postpartum, as pregnancy accelerates retinopathy progression, with a strength of evidence level of B 6, 1, 2
Patients with gestational diabetes do not require screening as they are not at increased risk for diabetic retinopathy, with a strength of evidence level of C 3