Diabetic retinopathy
At a glance
Retinal microvascular disease from diabetes. Classify retinopathy severity and macular oedema separately.
CAVE
- Look for neovascularisation of the disc, retina or iris, vitreous haemorrhage and traction.
- Pregnancy can change monitoring needs.
Clinical presentation
- Early disease is often silent.
- Haemorrhages, microaneurysms, venous changes and neovascularisation define the clinical pattern.
| Finding | Action | Timing / detail |
|---|---|---|
| Mild NPDR | Microaneurysms only | Assess macular oedema separately at every stage |
| Moderate NPDR | More than microaneurysms alone, but below severe criteria | NICE untreated disease: usually review every 6–12 months |
| Severe NPDR: any 4-2-1 criterion, without PDR | >20 intraretinal haemorrhages in each of 4 quadrants, definite venous beading in ≥2 quadrants, or prominent IRMA in ≥1 quadrant | Two or more criteria: very severe NPDR; NICE severe/very severe untreated disease: 3–6 months |
| PDR | Disc/elsewhere neovascularisation and/or preretinal/vitreous haemorrhage attributable to proliferative disease | Prompt retinal treatment assessment; symptoms, traction and high-risk findings increase urgency |
Diagnosis & investigations
- Record diabetes duration/type, HbA1c trend, blood pressure, kidney disease, pregnancy and previous retinal treatment. Grade each eye from a dilated examination and suitable imaging; perform OCT for suspected oedema or unexplained acuity loss.
- Distinguish IRMA within the retina from neovascular growth extending beyond the internal limiting membrane; angiography/OCT angiography can clarify uncertain lesions. Record macular oedema separately from the retinopathy grade. Extensive haemorrhage obscuring the fundus requires ultrasound to exclude tractional or rhegmatogenous detachment.
Differential diagnosis
- Retinal vein occlusion, hypertensive retinopathy, ocular ischaemia and other vascular retinopathies.
Treatment
- Coordinate glycaemia, blood pressure and renal care. Inform the diabetes team when substantial retinopathy accompanies a planned rapid HbA1c reduction so that retinal monitoring is arranged.
- For PDR, discuss prompt PRP and anti-VEGF according to macular oedema, traction, access and likelihood of sustained follow-up. PRP offers durability; anti-VEGF needs continuing surveillance and retreatment. Loss to follow-up after injection-only management can be hazardous. Macula-threatening traction or non-clearing vitreous haemorrhage warrants vitreoretinal assessment.
Follow-up
- Use the staging intervals below only for the specified untreated population. Active PDR, macular treatment or postoperative disease requires a treatment-specific schedule. Shorten intervals for progression, pregnancy, rapid metabolic change or unreliable attendance. New floaters, a curtain or acute visual loss require urgent examination rather than the screening appointment.
Risk factors & context
- Duration of diabetes, glycaemic control, blood pressure, nephropathy and pregnancy influence surveillance.
- Coordinate major metabolic treatment changes with the diabetes team.
Complications
- Macular oedema, vitreous haemorrhage, tractional detachment and neovascular glaucoma are the principal sight-threatening complications.
When to refer
- Prompt retina referral for proliferative changes, vitreous haemorrhage, traction or significant macular oedema.
References 2
- AAO · Diabetic Retinopathy Preferred Practice Pattern ↗2025 · Diagnosis; management; follow-up
- NICE · Diabetic retinopathy: management and monitoring ↗NG242 · 13 August 2024 · 1.3 Non-proliferative retinopathy; 1.4 Proliferative retinopathy; monitoring
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