# Diabetic Retinopathy

Manage diabetic retinopathy by separating nonproliferative disease, center-involving macular edema, and proliferative complications; use OCT and targeted angiography to define threat, maintain surveillance proportional to severity, and select anti-VEGF therapy, laser, or vitrectomy when anatomy, vision, or treatment adherence changes the balance.

**Clinical question:** How should physicians screen, stage, monitor, and treat diabetic retinopathy, diabetic macular edema, and proliferative complications?

Updated: 2026-09-16T00:15:22.207592+00:00

## What matters in practice
- Screen type 2 diabetes at diagnosis and type 1 diabetes beginning 5 years after onset; continue at least annual retinal assessment unless disease severity requires shorter surveillance. [18][19]
- Use structural OCT to assess suspected diabetic macular edema; reserve fluorescein angiography for vascular leakage, nonperfusion, uncertain neovascularization, or treatment planning. [12][20]
- Treat center-involving diabetic macular edema with intravitreal anti-VEGF therapy as first-line pharmacologic treatment; focal/grid laser remains principally useful for non-center-involving edema. [3][12]
- Detecting retinal neovascularization changes management from observation to proliferative-disease treatment with panretinal photocoagulation and/or intravitreal anti-VEGF, accounting for visit reliability and traction. [21][23]
- Refer for pars plana vitrectomy when proliferative disease causes nonresolving vitreous hemorrhage, macula-involving or macula-threatening tractional retinal detachment, combined tractional-rhegmatogenous detachment, or dense premacular hemorrhage. [9]

## Who needs retinal examination and when should referral accelerate?

Use diabetes type, pregnancy status, image quality, and retinopathy severity to set the interval.

For type 2 diabetes, obtain a dilated fundus examination or validated retinal photographic assessment at diagnosis, then at least annually. For type 1 diabetes, begin annual screening 5 years after disease onset. Retinal photography is an acceptable screening pathway when images are gradable and linked to a defined referral process; an ungradable photograph requires eye examination rather than reassurance. [16][18][19]

Shorten follow-up once nonproliferative diabetic retinopathy (NPDR) is identified. Mild-to-moderate NPDR is generally followed every 6 to 12 months, whereas severe NPDR and non-high-risk proliferative diabetic retinopathy (PDR) warrant examinations every 2 to 4 months because progression to vision-threatening disease is more likely. The likelihood of diabetic macular edema rises with NPDR severity: 15.6% with mild, 44.6% with moderate, and 62.6% with severe NPDR. [23]

Expedite retina evaluation for reduced vision, suspected center-involving diabetic macular edema (DME), severe NPDR, any retinal or disc neovascularization, vitreous/preretinal hemorrhage, or suspected tractional retinal detachment. These findings identify sight-threatening diabetic retinopathy and require management beyond routine screening. [15][17][21]
- At screening, document visual acuity, laterality, retinopathy severity, presence or absence of DME, image gradability, and the next examination interval; this prevents loss of follow-up after photographic screening. [15][16]
- Before planned pregnancy, obtain a retinal examination in patients with pre-existing diabetes; during pregnancy, examine in the first trimester or soon after conception. [13][14][15]
- During pregnancy, follow no/mild/moderate NPDR every 3 to 12 months and severe NPDR or PDR every 1 to 3 months; timing should be individualized by baseline severity and progression. [14][15]

*Surveillance and referral decisions by retinopathy state. [15][16][18][19][23]*

| Clinical state | Next action | Timing trigger |
| --- | --- | --- |
| Type 2 diabetes without documented eye examination | Dilated examination or retinal photographic screening. | At diabetes diagnosis. [16][18] |
| Type 1 diabetes without retinopathy | Begin annual retinal screening. | 5 years after disease onset. [18][19] |
| Mild or moderate NPDR | Monitor for DME and retinopathy progression. | Every 6–12 months. [23] |
| Severe NPDR or non-high-risk PDR | Retina-directed assessment and closer monitoring. | Every 2–4 months. [23] |
| Ungradable retinal photograph | Do not assign a routine screening interval; obtain eye examination. | Promptly after failed screening image. [16] |

## How should imaging separate edema, ischemia, and neovascularization?

Pair dilated examination with the imaging modality that answers the immediate management question.

Obtain structural macular OCT when visual symptoms, reduced acuity, retinal thickening, or exudates raise concern for DME. OCT determines whether edema involves the center and provides an anatomic baseline for anti-VEGF, corticosteroid, laser, or traction-directed decisions. Fluorescein angiography (FA) remains the reference angiographic test when the question is leakage, retinal nonperfusion, intraretinal microvascular abnormalities, or neovascularization. [12][20]

Use FA when clinical examination does not adequately define the leakage pattern, ischemic burden, or suspected proliferative lesion. On FA, microaneurysms appear as punctate hyperfluorescence, while nonperfusion appears as hypofluorescent capillary-deficient areas bordered by larger retinal vessels. Identifying neovascularization supports treatment of PDR to prevent vitreous hemorrhage and tractional retinal detachment. [20][21]

OCT angiography (OCTA) can depict superficial and deep plexus nonperfusion and foveal avascular zone changes without dye, but flow deficits may represent capillary occlusion, true dropout, or flow below detection threshold. Use OCTA as adjunctive multimodal imaging rather than a sole determinant of severity or treatment, especially when artifact, segmentation error, or a need to demonstrate leakage limits interpretation. [5][20]
- Use B-scan ultrasonography when media opacity from vitreous hemorrhage prevents adequate fundus examination and retinal detachment must be excluded. [20]
- In DME, assess center involvement and serial OCT change together with visual acuity; anatomic improvement alone does not substitute for functional assessment. [8][12]
- When OCT identifies vitreomacular traction or an epiretinal tractional component, shift the treatment discussion from pharmacologic edema control toward possible vitreoretinal surgical assessment. [11]

*Imaging selection for common diabetic retinopathy decisions. [12][20]*

| Clinical question | Preferred test | Result that changes management |
| --- | --- | --- |
| Is vision loss due to center-involving DME? | Structural macular OCT. | Center involvement establishes the anatomic context for intravitreal therapy decisions. [12] |
| Where is vascular leakage or macular nonperfusion? | Fluorescein angiography. | Leakage, nonperfusion, and neovascularization guide laser and proliferative-disease planning. [20] |
| Is there retinal detachment behind dense vitreous hemorrhage? | B-scan ultrasonography. | Detection of detachment prompts urgent surgical assessment. [20] |
| What is the capillary plexus and FAZ morphology without dye? | OCTA as an adjunct. | Nonperfusion metrics require correlation because absent flow signal is not synonymous with irreversible capillary loss. [20] |

## How should diabetic macular edema drive treatment selection?

The primary branch is center involvement, visual impact, and whether the eye has a tractional component.

For center-involving DME with visual impairment, offer intravitreal anti-VEGF therapy as first-line pharmacologic treatment. Anti-VEGF therapy improves visual and anatomic outcomes and has displaced macular laser as the routine initial intervention for center-involving edema. Dosing schedules should follow the selected agent's current U.S. label and the treating retina service's protocol because the cited evidence supports treatment class selection but does not establish a universal regimen. [3][4][12]

For non-center-involving DME, focal or grid laser remains a key treatment option. In focal clinically significant macular edema without foveal involvement, focal treatment of microaneurysms and localized leakage reduced moderate visual loss from 24% to 12%; reassess persistent leakage after 2 to 3 months and consider repeat laser. [12][21]

Consider intravitreal corticosteroid therapy, including dexamethasone implant, when anti-VEGF is unsuitable or response is insufficient, particularly in pseudophakic adults. This tradeoff requires individualized selection because corticosteroid treatment is an alternative rather than routine first-line therapy in center-involving DME. [3][4][12]

For patients who can maintain injection visits and desire fewer treatment encounters, extended-interval regimens may be appropriate. In the 96-week PHOTON trial, aflibercept 8 mg every 12 or 16 weeks after three monthly doses was noninferior to aflibercept 2 mg every 8 weeks after five monthly doses in center-involving DME, with fewer injections; faricimab also demonstrated extended durability in YOSEMITE and RHINE. [23][24]
- Do not use a stable OCT result alone to stop treatment; integrate visual acuity, OCT thickness, and recurrence risk when deciding whether to continue, defer, or extend injections. [8]
- If edema persists after a deferred-laser strategy, DRCR protocols added focal/grid laser at or after 24 weeks when edema remained and OCT or vision was no longer improving. [8]
- Optimize systemic glycemic and blood-pressure management alongside ocular therapy; HbA1c no higher than 7.0% and blood pressure below 130/80 mm Hg have evidence for reducing or delaying retinopathy progression. [12]

*Treatment branch for diabetic macular edema. [3][4][8][12][21][23]*

| DME pattern | Usual treatment direction | Reassessment or escalation |
| --- | --- | --- |
| Center-involving DME with visual impairment | Initiate intravitreal anti-VEGF therapy. [3][12] | Track visual acuity and OCT response; consider interval extension only after disease control. [8][23] |
| Non-center-involving focal DME | Use focal/grid laser for focal leakage. [12][21] | If leakage persists, reassess at 2–3 months for repeat laser. [21] |
| Insufficient anti-VEGF response or anti-VEGF unsuitable | Consider intravitreal corticosteroid treatment; pseudophakia favors this option in selected adults. [3][4][12] | Reassess anatomy and visual function; exclude a tractional mechanism. [11] |
| Vitreomacular traction contributing to DME | Obtain vitreoretinal surgical assessment rather than escalating edema-directed injections alone. [11] | Determine whether traction threatens the macula or causes progressive visual loss. [11] |

## When should PDR receive panretinal photocoagulation, anti-VEGF, or both?

The treatment objective is to suppress neovascular complications before hemorrhage or traction compromises vision.

Treat retinal or disc neovascularization as PDR. Panretinal photocoagulation (PRP) reduces the ischemic drive for neovascularization and is performed to prevent vitreous hemorrhage and tractional retinal detachment. PRP is particularly valuable when reliable repeated intravitreal treatment cannot be assured, because its effect does not depend on continuous injection attendance. [21][23]

Intravitreal anti-VEGF therapy is a treatment option for PDR and may be combined with PRP, particularly when PDR coexists with center-involving DME. In current practice, many retina specialists use both treatments for high-risk PDR with center-involving DME. The key tradeoff is rapid pharmacologic neovascular regression versus the need for ongoing visits and the potential for tractional change in eyes with extensive fibrovascular proliferation. [23][24]

Assess each PDR eye for vitreous hemorrhage, fibrovascular membranes, macular traction, and retinal detachment before choosing injection-only management. In eyes with pre-existing tractional disease, laser and anti-VEGF can alter fibrovascular tissue and may rapidly worsen traction; the presence of macula-threatening traction should shift management toward surgical planning. [11]
- Use FA when the extent of neovascularization or nonperfusion is uncertain on examination and the result will guide PRP planning. [20][21]
- Do not defer treatment of high-risk PDR solely because visual acuity is preserved; the purpose of treatment is prevention of hemorrhagic and tractional complications. [14][21]
- In pregnancy, laser is the preferred established approach for high-risk PDR; avoid anti-VEGF and triamcinolone when possible because of fetal safety concerns. [14]

### PDR in pregnancy

Establish severity before conception when possible and perform needed laser before pregnancy in patients with severe NPDR, PDR, or DME. During pregnancy, progression risk is greatest in patients with pre-existing retinopathy, poor preconception glycemic control, hypertension, and prior retinopathy treatment; surveillance therefore must be more intensive than routine annual screening. [13][15]
- Diabetic retinopathy alone is not a contraindication to vaginal delivery. [13][14]
- Avoid intravitreal anti-VEGF and triamcinolone during pregnancy when possible; if use is contemplated for a vision-threatening indication, require individualized retina and maternal-fetal risk assessment. [14]

*PDR treatment selection by complication and follow-up feasibility. [11][21][23]*

| PDR presentation | Management priority | Key limitation or escalation trigger |
| --- | --- | --- |
| Neovascularization without major traction | PRP and/or intravitreal anti-VEGF. [21][23] | Injection-based control requires ongoing reliable follow-up. [23] |
| High-risk PDR with center-involving DME | Anti-VEGF treatment with concurrent or future PRP commonly used. [23] | Monitor for recurrent edema, neovascular activity, and missed visits. [23] |
| Extensive fibrovascular proliferation or traction | Assess urgently for surgical strategy before or alongside pharmacologic treatment. [11] | Laser or anti-VEGF may worsen traction through fibrovascular change. [11] |
| PDR during pregnancy | Use laser for high-risk disease when treatment is required. [14] | Avoid anti-VEGF and triamcinolone when possible. [14] |

## When is pars plana vitrectomy indicated and how should preoperative anti-VEGF be timed?

Vitrectomy addresses hemorrhage and tractional anatomy that laser or injections cannot reliably resolve.

Refer for pars plana vitrectomy (PPV) in PDR with nonresolving vitreous hemorrhage, tractional retinal detachment involving or threatening the macula, combined tractional-rhegmatogenous retinal detachment, or dense premacular hemorrhage. In a dense hemorrhage that prevents fundus visualization, use B-scan ultrasonography to identify detachment and prioritize urgent surgical review when the macula is threatened. [9][20]

Preoperative anti-VEGF may reduce neovascularization and intraoperative bleeding, facilitating fibrovascular membrane dissection. However, in severe tractional PDR, delayed surgery after injection can permit progressive fibrosis and tractional macular detachment. In one cited analysis, tractional macular detachment occurred in 2.7% when injection was given within 6 days of PPV versus 56% when given more than 10 days preoperatively; if anti-VEGF is used as a surgical adjunct, coordinate injection with a short, fixed path to surgery rather than an open-ended delay. [2]

Surgical goals are to release traction, reattach the retina when detached, clear nonresolving hemorrhage, and apply retinal laser to ischemic retina. Small extrafoveal tractional retinal detachments may remain stable for years and can sometimes be managed with laser rather than immediate PPV, but new macular involvement, progressive traction, or visual decline warrants surgical reassessment. [11]
- Do not use preoperative anti-VEGF without confirming that the patient can proceed to timely PPV when extensive tractional fibrovascular disease is present. [2][11]
- For nonresolving PDR vitreous hemorrhage that blocks adequate PRP and causes major visual disability, PPV is an important operative option. [9]
- After PPV, continue surveillance for recurrent neovascularization, recurrent vitreous hemorrhage, and retinal detachment. [9][11]

*Operative triage in complicated proliferative diabetic retinopathy. [2][9][11][20]*

| Finding | Immediate diagnostic or treatment action | Timing implication |
| --- | --- | --- |
| Dense vitreous hemorrhage obscuring retina | B-scan ultrasonography; evaluate whether PRP is possible and whether PPV is indicated. [9][20] | Urgent surgical assessment if detachment is identified or suspected. [20] |
| Macula-involving or macula-threatening TRD | PPV evaluation to relieve traction and reattach retina. [9][11] | Do not permit prolonged delay after preoperative anti-VEGF. [2] |
| Combined tractional-rhegmatogenous retinal detachment | PPV is indicated. [9] | Prompt retina surgery planning. [9] |
| Preoperative anti-VEGF in complex PDR | Use only with coordinated PPV scheduling to reduce bleeding and facilitate dissection. [2] | Short interval is favored; delay beyond 10 days was associated with more tractional macular detachment in cited data. [2] |

## References
1. Comparison of diabetic retinopathy classification using fluorescein angiography and optical coherence tomography angiography | British Journal of Ophthalmology — bjo.bmj.com — https://bjo.bmj.com/content/101/1/62.abstract
2. Perioperative anti-vascular endothelial growth factor agents treatment in patients undergoing vitrectomy for complicated proliferative diabetic retinopathy: a network meta-analysis | Scientific Reports — www.nature.com — https://www.nature.com/articles/s41598-020-75896-8
3. Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group | Eye — www.nature.com — https://www.nature.com/articles/s41433-020-0961-6
4. Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease | Eye — www.nature.com — https://www.nature.com/articles/eye201753
5. Optical coherence tomography angiography in diabetic retinopathy: A major review - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S0039625724000213
6. Comparison Between Graders in Detection of Diabetic Neovascularization With Swept Source Optical Coherence Tomography Angiography and Fluorescein Angiography - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S0002939420306541
7. Association of OCT Angiography-Detected Intraretinal Microvascular Abnormalities with Diabetic Retinopathy Severity - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S2468653025003690
8. Diabetic Retinopathy Classification - an overview | ScienceDirect Topics — www.sciencedirect.com — https://www.sciencedirect.com/topics/medicine-and-dentistry/diabetic-retinopathy-classification
9. Perioperative anti-vascular endothelial growth... : Indian Journal of Ophthalmology — journals.lww.com — https://journals.lww.com/ijo/_layouts/15/oaks.journals/downloadpdf.aspx?an=02223307-202605000-00011
10. Retina Spotlight: Diabetic Retinopathy - Preferred Practice Patterns — journals.lww.com — https://journals.lww.com/tnoa/_layouts/15/oaks.journals/downloadpdf.aspx?an=02079083-201755020-00007
11. Vitrectomy for diabetic retinopathy: A review of... : Taiwan Journal of Ophthalmology — journals.lww.com — https://journals.lww.com/tjop/fulltext/2024/14040/vitrectomy_for_diabetic_retinopathy__a_review_of.8.aspx
12. Evidence-based review of diabetic macular edema... : Indian Journal of Ophthalmology — journals.lww.com — https://journals.lww.com/ijo/_layouts/15/oaks.journals/downloadpdf.aspx?an=02223307-201664010-00004
13. Current Trends in Diagnosis and Treatment Approach of Diabetic Retinopathy during Pregnancy: A Narrative Review — pmc.ncbi.nlm.nih.gov — https://pmc.ncbi.nlm.nih.gov/articles/PMC10887682
14. Diabetic retinopathy in pregnancy - A review — pmc.ncbi.nlm.nih.gov — https://pmc.ncbi.nlm.nih.gov/articles/PMC8725079
15. Nonmydriatic Photographic Screening for Diabetic Retinopathy in Pregnant Patients with Pre-Existing Diabetes in a Safety Net Population: 1 Year Results from the Diabetic Retinopathy in Pregnant Patients Study - PMC — pmc.ncbi.nlm.nih.gov — https://pmc.ncbi.nlm.nih.gov/articles/PMC7784768
16. Recently updated global diabetic retinopathy screening guidelines: commonalities, differences, and future possibilities — pmc.ncbi.nlm.nih.gov — https://pmc.ncbi.nlm.nih.gov/articles/PMC8452707
17. Guidelines on Diabetic Eye Care: The International Council of Ophthalmology Recommendations for Screening, Follow-up, Referral, and Treatment Based on Resource Settings - PubMed — pubmed.ncbi.nlm.nih.gov — https://pubmed.ncbi.nlm.nih.gov/29776671
18. Diabetic Retinopathy - StatPearls - NCBI Bookshelf — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/books/NBK560805
19. Diabetic Retinopathy Preferred Practice Pattern® - Ophthalmology — www.aaojournal.org — https://www.aaojournal.org/article/S0161-6420(19)32092-5/fulltext
20. Optical Coherence Tomography Angiography in Diabetes and Diabetic Retinopathy - PMC — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357089
21. Diabetic retinopathy - ocular complications of diabetes mellitus - PMC — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4398904?term=%22World+J+Diabetes%22%5Bjour%5D
22. Fenofibrate for diabetic retinopathy (Review) - Cochrane Library — www.cochranelibrary.com — https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013318.pub2/pdf/full
23. Print Article | Cleveland Clinic Journal of medicine — www.ccjm.org — https://www.ccjm.org/custom-print/80745
24. Diabetic retinopathy: Screening, prevention, and treatment | Cleveland Clinic Journal of medicine — www.ccjm.org — https://www.ccjm.org/content/91/8/503

## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.