Diabetic Retinopathy

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Risk Factors

  • Duration of diabetes mellitus
  • Poorly controlled diabetes: target HbA1c approx. 7%.
  • Arterial hypertension: rigorous blood pressure control recommended
  • Renal insufficiency
  • Dyslipidaemia
  • Pregnancy


  • Mild non-proliferative diabetic retinopathy (NPDR): microaneurysms
  • Moderate NPDR: additional retinal haemorrhages, cotton wool foci
  • Severe NPDR: any of the following findings (= 4-2-1 rule)
    • major haemorrhages and microaneurysms in 4 quadrants
    • venous beading in at least 2 quadrants
    • intraretinal microvascular abnormalities (IRMAs = dilated, tortuous capillaries or intraretinal neovascularisations) in at least 1 quadrant
  • Proliferative diabetic retinopathy (PDR): Neovascularisations (optic disc 1, iris 2, chamber angle, retina (NVE=elsewhere)) or vitreous haemorrhage.
  • with/without macular oedema:
    • Clinically significant macular oedema according to ETDRS 3
      • Oedema within 500µm of fovea
      • Hard exudates within 500µm of fovea if associated with oedema
      • Retinal thickening of ≥1 optic disc diameter within 1 optic disc diameter to centre of macula
    • OCT findings and visual acuity are decisive for anti-VEGF injections
      • OCT: fluid within 500µm of fovea
      • Visual acuity: initial visual acuity? stable/getting worse?


  • No diabetic retinopathy: annually
  • Mild: 6-12 monthly
  • Moderate: 6-monthly
  • Severe: at least 2-4 monthly
  • Proliferative 1-3-monthly
  • Macular oedema: initially monthly

Workup and Management

  • OCT, Fluorescein angiography if proliferative diabetic retinopathy is suspected, otherwise funduscopic diagnosis
  • Severe NPDR: Consider panretinal laser
    • in case of proliferative retinopathy of the fellow eye
    • in patients with poor adherence to treatment
  • Proliferative (PDR): panretinal laser coagulation recommended
    • consider anti-VEGF (e.g. for chamber angle neovascularisation )
  • Macular oedema: anti-VEGF therapy
    • Consider switching to steroid (e.g. Ozurdex=Dexamethasone) if there is no sufficient response after 6-12 months
      • CAVE: May induce cataract and IOP elevations
  • In vitreous haemorrhage: consider Pars Plana Vitrectomy (PPV)


  • EyeWiki Diabetic Retinopathy
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)
  • 1, 2, 3 von Eyerounds.org, © The University of Iowa; Licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
    • 1 Contributor: Christopher Kirkpatrick, MD; Photographer: Samantha Jacobo
    • 2 Contributor: Johanna Beebe, MD, Jaclyn Haugsdal, MD; Photographer: Cindy Montague, CRA
    • 3 Contributor: Ben J. Janson, MD; Photographer: Brice Critser