Diabetic retinopathy Diagnosis and management Indications for screening Q Does the patient have T1DM of 5 years duration? Q Does the patient have T2DM? No to all Consider alternative diagnoses. Yes to any 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 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 Serial eye examinations Patients without retinopathy Q Does the patient have evidence of diabetic retinopathy? No 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 Yes 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 Indications for referral Q Does the patient have any level of macular edema? Q Does the patient have severe nonproliferative diabetic retinopathy? Q Does the patient have proliferative diabetic retinopathy? No to all Repeat dilated retinal examinations at least annually if there is any level of DR. Obtain ocular examinations more frequently id retinopathy is progressing or sight-threatening. B Yes to any 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 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 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 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 retinopathy is progressing or sight-threatening. B