Guideline sources The following summarized guidelines for the evaluation and management of diabetic retinopathy (DR) are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023). 1 2 2 3 Definition Diabetic retinopathy is a chronic microvascular complication of diabetes characterized by visual impairment in one or both the eyes. Epidemiology DR is caused due to uncontrolled longstanding hyperglycemia. 2 Disease course Clinical manifestations of DR include microaneurysms, dot and blot hemorrhages, hard exudates, cotton wool spots, intraretinal microvascular abnormalities, and retinal edema in non- proliferative DR. Severe non-proliferative DR progresses to proliferative DR characterized by neovascularization. Progressive DR results in diabetic macular edema and permanent visual loss. 2 Prognosis and risk of recurrence https://web.pathway.md/diseases/rec4yr6vMjoFc8FDi 1/4 6/29/23, 10:16 PM Diabetic retinopathy Pathway DR is associated with increased all-cause mortality and cardiovascular events risk with an odds ratio of 2.34 (95% CI 1.96-2.80]. 3 Pathway Diabetic retinopathy Diagnosis and management Guidelines 1. Screening and diagnosis Indications for screening: Obtain an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of T1DM and at the time of diagnosis in patients with T2DM. B Consider employing programs using retinal photography (with remote reading or the use of a validated assessment tool) to improve access to DR screening. Ensure that such programs provide pathways for timely referral for a comprehensive eye examination when indicated. C 2. Medical management Glycemic control: optimize glycemic control to slow the progression of DR. A Cardiovascular risk factor control: optimize BP and control dyslipidemia to slow the progression of DR. A Management of antiplatelet agents: recognize that the presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage. A 3. Therapeutic procedures Intravitreous anti-VEGF injections: Consider administering intravitreal injections of anti-VEGF as an alternative to traditional panretinal laser photocoagulation in some patients with proliferative DR and also reduce the risk of vision loss in these patients. B Administer intravitreal injections of anti-VEGF as first-line therapy in most eyes with diabetic macular edema involving the foveal center and impairing vision acuity. A Intravitreous corticosteroid injections: consider administering intravitreal injections of corticosteroids in eyes with persistent diabetic macular edema despite previous anti-VEGF therapy or eyes not being candidates for this first-line approach. B https://web.pathway.md/diseases/rec4yr6vMjoFc8FDi 2/4 6/29/23, 10:16 PM Diabetic retinopathy Pathway Laser photocoagulation: Perform panretinal laser photocoagulation therapy to reduce the risk of vision loss in patients with high-risk proliferative DR and, in some cases, severe nonproliferative DR. A Consider performing macular focal/grid photocoagulation in patients with persistent diabetic macular edema despite previous anti-VEGF therapy or eyes not being candidates for this first-line approach. B 4. Specific circumstances Pediatric patients: obtain an initial dilated and comprehensive eye examination once the patient has had T1DM for 3-5 years, provided the patient is aged 11 years or puberty has started, whichever is earlier. Obtain repeat dilated and comprehensive eye examinations every 2 years after the initial examination. Consider obtaining less frequent examinations, every 4 years, on the advice of an eye care professional and based on risk factor assessment, including a history of HbA1c < 8%. B Show 3 more Pregnant patients: Counsel pregnant patients or patients planning a pregnancy with preexisting diabetes on the risk of development and/or progression of DR. B Obtain an eye examination before pregnancy or in the first trimester in patients with preexisting diabetes. Monitor patients every trimester and for 1 year postpartum as indicated by the degree of retinopathy. B 5. Preventative measures Primary prevention (glycemic control): optimize glycemic control to reduce the risk of DR. A Primary prevention (cardiovascular risk factor control): optimize BP and control dyslipidemia to reduce the risk of developing DR. A 6. Follow-up and surveillance Indications for referral: Refer patients with any of the following to an ophthalmologist knowledgeable and experienced in the management of DR: any level of diabetic macular edema moderate or worse nonproliferative DR (a precursor of proliferative DR) any proliferative DR. A Serial eye examinations (patients without retinopathy): consider repeating screening every 1-2 years if there is no evidence of retinopathy for 1 annual eye exam and glycemia is well controlled. C Serial eye examinations (patients with retinopathy): repeat dilated retinal examinations at least annually if there is any level of DR. Obtain ocular examinations more frequently id https://web.pathway.md/diseases/rec4yr6vMjoFc8FDi 3/4 6/29/23, 10:16 PM Diabetic retinopathy Pathway retinopathy is progressing or sight-threatening. B Clinical findings Symptoms Past medical history Blurred vision Diabetes mellitus Eye pain Dyslipidemia Floaters and flashes Hypertension Vision loss Poorly controlled diabetes Neurological exam Ocular exam Visual field defect Cotton wool spots Macular edema Lab findings Retinal hemorrhage Retinal microaneurysms Hyperglycemia visual acuity References 1. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 2. Ramandeep Singh, Kim Ramasamy, Chandran Abraham et al. Diabetic retinopathy: an update. May- Jun 2008;56 3 178 88.May-Jun 2008;56 3 178 88. Open 3. Caroline K Kramer, Ticiana C Rodrigues, Luis H Canani et al. Diabetic retinopathy predicts all-cause mortality and cardiovascular events in both type 1 and 2 diabetes: meta-analysis of observational studies. 2011 May;34 5 1238 44.2011 May;34 5 1238 44. Open 4. American Diabetes Association. Standards of Medical Care in Diabetes-2019 Abridged for Primary Care Providers. Clin Diabetes. 2019 Jan;37 1 11 34. Open 5. American Diabetes Association. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes 2019. Diabetes Care. 2019 Jan;42 Suppl 1 S124 S138. Open 6. Ramandeep Singh, Kim Ramasamy, Chandran Abraham et al. Diabetic retinopathy: An update. Indian J Ophthalmol. 2008 May-Jun; 56 3 179 188. Open 7. Caroline K. Kramer, Ticiana C. Rodrigues, Luis H. Canani et al. Diabetic Retinopathy Predicts All- Cause Mortality and Cardiovascular Events in Both Type 1 and 2 Diabetes. Diabetes Care. 2011 May; 34 5 1238 1244. Open 8. American Diabetes Association Professional Practice Committee, American Diabetes Association Professional Practice Committee:, Draznin B et al. Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45 Supplement_1 S1 S264. Open https://web.pathway.md/diseases/rec4yr6vMjoFc8FDi 4/4