Red Flags
- Sudden vision loss or new floaters with diabetes — emergency ophthalmology; suspect vitreous haemorrhage or tractional retinal detachment[1]
- Severe non-proliferative diabetic retinopathy (NPDR), proliferative DR, or diabetic macular oedema — same-week retinal specialist for laser, intravitreal therapy, or vitrectomy[1]
- Pregnancy with pre-existing diabetes — screen at booking and trimester progression; risk of rapid worsening[1]
- Severe hypoglycaemia or rapid HbA1c reduction in T1DM with established DR — early worsening of retinopathy ('treatment-induced retinopathy')[1]
First-line treatment
Interventions
- Glycaemic, BP, lipid optimisation[1]HbA1c <7% (individualised), BP <130/80, statin therapy; tight control reduces incidence and progression of DR; rapid intensification can transiently worsen — counsel and ophthalmology liaison
- Diabetic retinopathy screening pathway[1]Annual digital fundus photography with grading by trained reader/AI tool; refer to ophthalmology for any DR more advanced than mild NPDR or any maculopathy
- Pan-retinal photocoagulation (PRP)[1]Proliferative diabetic retinopathy; severe NPDR in selected high-risk patients; multiple sessions; transient peripheral vision loss; may combine with anti-VEGF for centre-involving DME
- Intravitreal anti-VEGF therapy[1]Diabetic macular oedema (centre-involving) and high-risk PDR; ranibizumab, bevacizumab (off-label), aflibercept, faricimab; monthly loading × 5 then variable per response
- Vitrectomy[1]Non-clearing vitreous haemorrhage, tractional retinal detachment, fibrovascular proliferation threatening macula; combined with PRP and intraoperative anti-VEGF where indicated
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Ranibizumab (intravitreal)[1] | Anti-VEGF Fab fragment | 0.5 mg intravitreal injection monthly × 4–5 doses then variable (PRN, treat-and-extend) | — | First-line for centre-involving DME; ophthalmology specialist administration; monitor IOP, endophthalmitis risk |
| Aflibercept (intravitreal)[1] | Anti-VEGF fusion protein | 2 mg intravitreal monthly × 5 doses then every 8 weeks; high-dose 8 mg with extended interval emerging | — | Comparable efficacy to ranibizumab; longer durability allowing extended intervals; durable PDR control in Protocol S |
| Bevacizumab (intravitreal — off-label)[1] | Anti-VEGF monoclonal antibody | 1.25 mg intravitreal monthly × 5 doses then variable | — | Cost-effective alternative widely used in resource-limited settings; off-label for ophthalmic use; comparable efficacy in Protocol T |
| Intravitreal triamcinolone or dexamethasone implant (refractory DME)[1] | Intravitreal corticosteroid | Triamcinolone 4 mg intravitreal; dexamethasone 0.7 mg sustained-release implant every 4–6 months | — | Refractory DME or anti-VEGF non-response; cataract progression and IOP rise; consider after multiple anti-VEGF failures or pseudophakic eye |
| Fenofibrate (selected)[1] | PPAR-alpha agonist | 200 mg PO daily | — | Adjunct for DR progression in patients with elevated triglycerides per FIELD trial; not a substitute for ophthalmic therapy |
Ranibizumab (intravitreal)[1]
Anti-VEGF Fab fragment
- Adult
- 0.5 mg intravitreal injection monthly × 4–5 doses then variable (PRN, treat-and-extend)
- Paediatric
- —
First-line for centre-involving DME; ophthalmology specialist administration; monitor IOP, endophthalmitis risk
Aflibercept (intravitreal)[1]
Anti-VEGF fusion protein
- Adult
- 2 mg intravitreal monthly × 5 doses then every 8 weeks; high-dose 8 mg with extended interval emerging
- Paediatric
- —
Comparable efficacy to ranibizumab; longer durability allowing extended intervals; durable PDR control in Protocol S
Bevacizumab (intravitreal — off-label)[1]
Anti-VEGF monoclonal antibody
- Adult
- 1.25 mg intravitreal monthly × 5 doses then variable
- Paediatric
- —
Cost-effective alternative widely used in resource-limited settings; off-label for ophthalmic use; comparable efficacy in Protocol T
Intravitreal triamcinolone or dexamethasone implant (refractory DME)[1]
Intravitreal corticosteroid
- Adult
- Triamcinolone 4 mg intravitreal; dexamethasone 0.7 mg sustained-release implant every 4–6 months
- Paediatric
- —
Refractory DME or anti-VEGF non-response; cataract progression and IOP rise; consider after multiple anti-VEGF failures or pseudophakic eye
Fenofibrate (selected)[1]
PPAR-alpha agonist
- Adult
- 200 mg PO daily
- Paediatric
- —
Adjunct for DR progression in patients with elevated triglycerides per FIELD trial; not a substitute for ophthalmic therapy
Safety-net
- Annual eye check is essential even when vision feels normal — diabetic retinopathy is silent until advanced[1]
- Sudden vision loss, new floaters, flashes, or sudden blurry vision — same-day ophthalmology assessment[1]
- Tight control of blood sugar and BP slows or prevents progression — but rapid HbA1c drops can transiently worsen retinopathy; coordinate with eye team[1]
Referral criteria
- Any DR more advanced than mild NPDR; any diabetic macular oedemaOphthalmology / retina specialist[1]
- Sudden vision loss, vitreous haemorrhage, tractional retinal detachment, neovascular glaucomaEmergency ophthalmology[1]
- Pregnancy with pre-existing diabetesScreen at booking and trimester progression[1]
- Failure of anti-VEGF or refractory DMETertiary retinal service for combined therapy or alternative agent[1]
Clinical summary
Screening, staging, and treatment pathway for diabetic retinopathy and diabetic macular oedema in adults with type 1 and type 2 diabetes.