Guidelines Summary

The American Diabetes Association’s “Standards of Medical Care in Diabetes-2018” include the following recommendations regarding diabetic retinopathy^[49]:

Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy
Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy
Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes
Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis
If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well controlled, then exams every 1-2 years may be considered; if any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist; if retinopathy is progressing or sight-threatening, then examinations will be required more frequently
While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam
Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy
Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy
Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy to an ophthalmologist who is knowledgeable and experienced in the management of diabetic retinopathy
The traditional standard treatment, panretinal laser photocoagulation therapy, is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy
Intravitreous injections of the vascular endothelial growth factor inhibitor ranibizumab are not inferior to traditional panretinal laser photocoagulation and are also indicated to reduce the risk of vision loss in patients with proliferative diabetic retinopathy
Intravitreous injections of vascular endothelial growth factor inhibitor are indicated for central-involved diabetic macular edema, which occurs beneath the foveal center and may threaten reading vision
The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage

Medication

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Media Gallery

Fundus photograph of early background diabetic retinopathy showing multiple microaneurysms.
Retinal findings in background diabetic retinopathy, including blot hemorrhages (long arrow), microaneurysms (short arrow), and hard exudates (arrowhead).
Fluorescein angiogram demonstrating an area of capillary nonperfusion (arrow).
Fluorescein angiogram demonstrating foveal dye leakage caused by macular edema.
Fundus photograph of clinically significant macular edema demonstrating retinal exudates within the fovea.
New vessel formation on the surface of the retina (neovascularization elsewhere)
An area of neovascularization that leaks fluorescein on angiography.
Boat-shaped preretinal hemorrhage associated with neovascularization elsewhere.
Fibrovascular proliferations within the vitreous cavity
Extensive fibrovascular proliferations within and around the optic disc

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Author

Abdhish R Bhavsar, MD Adjunct Assistant Professor, Department of Ophthalmology, University of Minnesota Medical School; Director of Clinical Research, Retina Center, PA; Past Chair, Consulting Staff, Department of Ophthalmology, Phillips Eye Institute

Abdhish R Bhavsar, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Minnesota Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Neal H Atebara, MD Private Practice, Retina Center of Hawaii

Neal H Atebara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Retina Society, American Medical Association, Hawaii Medical Association

Disclosure: Nothing to disclose.

John H Drouilhet, MD, FACS Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine

John H Drouilhet, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Steve Charles, MD Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

V Al Pakalnis, MD, PhD Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sherman O Valero, MD, to the development and writing of this article.

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