What are the guidelines for eye exams in individuals with diabetes?

Diabetes Eye Exam Guidelines

All individuals with type 2 diabetes should have a dilated comprehensive eye examination by an ophthalmologist or optometrist immediately at the time of diagnosis, while those with type 1 diabetes should be examined within 5 years of diagnosis. 1

Initial Screening Timing

Type 1 Diabetes

• First eye exam within 5 years after diabetes onset, as retinopathy typically requires at least 5 years of hyperglycemia to develop 1
• Generally not necessary before age 10 years, though clinical judgment should guide decisions for individual patients, particularly considering prepubertal diabetes duration 1

Type 2 Diabetes

• Immediate dilated comprehensive eye examination at diagnosis because patients may have had years of undiagnosed diabetes and significant risk of prevalent retinopathy already exists 1

Pregnancy-Related Screening

• Women with preexisting type 1 or type 2 diabetes planning pregnancy require comprehensive eye examination before conception and in the first trimester, with close follow-up throughout pregnancy 1
• Gestational diabetes does not require special retinal screening, as these individuals are not at increased risk for diabetic retinopathy 1
• The risk of progression is substantial: 52.3% prevalence of any retinopathy and 6.1% prevalence of proliferative diabetic retinopathy in early pregnancy among those with preexisting diabetes 1

Follow-Up Examination Frequency

Standard Follow-Up

• Annual dilated retinal examinations for both type 1 and type 2 diabetes patients by an ophthalmologist or optometrist experienced in diabetic retinopathy 1

Extended Interval Option

• Every 1-2 years may be considered if there is no evidence of retinopathy from one or more annual exams AND glycemic indicators are within goal range 1
• This represents an evolution from older guidelines that recommended strict annual screening 1

Accelerated Monitoring

• At least annual examinations if any level of diabetic retinopathy is present 1
• More frequent than annual if retinopathy is progressing or sight-threatening 1

Alternative Screening Modalities

• Retinal photography with remote reading or FDA-approved artificial intelligence algorithms are appropriate screening strategies for diabetic retinopathy 1
• These programs must provide pathways for timely referral for comprehensive eye examination when indicated 1

Critical Referral Triggers

Immediate ophthalmology referral is required for:

• Any level of diabetic macular edema 1
• Severe nonproliferative diabetic retinopathy (NPDR) 1
• Any proliferative diabetic retinopathy (PDR) 1

Important Caveat on Timing

• Do not delay referral until PDR develops in patients with severe NPDR, as early treatment at the severe NPDR stage reduces risk of severe visual loss and vitrectomy by 50% in type 2 diabetes 1

Special Considerations with GLP-1 Receptor Agonists

• Assess retinopathy status before intensifying glucose-lowering therapy with GLP-1 RAs (liraglutide, semaglutide, dulaglutide), as these agents are associated with increased risk of rapidly worsening diabetic retinopathy in randomized trials 1
• Rapid reductions in A1C can be associated with initial worsening of retinopathy 1

Common Pitfalls to Avoid

Patient Education Gaps

• Approximately 30% of patients with diabetes are unaware of the need for annual dilated eye examinations 2
• Only 54.1% of Medicare beneficiaries with diabetes nationally received an eye exam in 2017, with state-level variation from 43.9% to 64.8% 3
• Among youths with diabetes, only 64.9% with type 1 and 42.2% with type 2 had undergone eye examination by 6 years after diagnosis 4

Health Disparities

• Black beneficiaries have 11% and Latino beneficiaries have 18% decreased likelihood of undergoing eye examination compared to white beneficiaries 4
• Lower household net worth significantly reduces likelihood of receiving examinations 4

Systemic Risk Factor Management

• Optimize glycemic control to reduce risk or slow progression of retinopathy 1
• Optimize blood pressure control to reduce risk or slow progression of retinopathy 1
• Address modifiable risk factors including hypertension, dyslipidemia, and smoking 5