Diabetic retinopathy

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]

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

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

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

Adjunct for DR progression in patients with elevated triglycerides per FIELD trial; not a substitute for ophthalmic therapy

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]

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]

Screening, staging, and treatment pathway for diabetic retinopathy and diabetic macular oedema in adults with type 1 and type 2 diabetes.

1.RSSDI-VRSI Position Statement on Diabetic Retinopathy Screening and Management (2023); ICO Guidelines for Diabetic Eye Care; AAO Diabetic Retinopathy Preferred Practice Pattern (2023)