What are the treatment options for diabetic retinopathy?

Diabetic Retinopathy Treatment

The treatment of diabetic retinopathy requires strict systemic risk factor control combined with stage-specific ophthalmic interventions: optimize glycemic control (near-normoglycemia), blood pressure (<130/80 mmHg), and lipids, while promptly referring patients with macular edema, severe nonproliferative diabetic retinopathy (NPDR), or any proliferative diabetic retinopathy (PDR) to an experienced ophthalmologist for anti-VEGF therapy or laser photocoagulation. 1, 2

Systemic Risk Factor Management (Foundation of All Treatment)

Blood glucose control is the single most important modifiable risk factor for preventing diabetic retinopathy onset and progression. 1, 2

• Target near-normoglycemia with HbA1c ≤7% for most patients 2, 3
• Critical caveat: Avoid rapid reduction in HbA1c in patients with existing retinopathy, as this can cause early worsening of disease 2, 3

Blood pressure control to <130/80 mmHg significantly reduces retinopathy progression and vision loss. 1, 2, 3

• Use ACE inhibitors or ARBs as first-line agents—both are effective specifically for diabetic retinopathy 2, 3
• Systolic targets <120 mmHg provide no additional benefit 3

Lipid management reduces retinopathy progression risk. 2, 3

• Optimize serum lipid control as part of comprehensive management 2, 3
• Consider adding fenofibrate, which may slow retinopathy progression particularly in patients with very mild NPDR 2, 3

Stage-Specific Ophthalmic Treatment

Mild to Moderate NPDR (No Macular Edema)

• Continue optimizing systemic risk factors (glycemic control, blood pressure, lipids) 2
• Annual dilated eye examinations by an ophthalmologist 2
• No laser or intravitreal therapy required at this stage 1

Severe NPDR

Consider panretinal laser photocoagulation (PRP), especially in patients with type 2 diabetes or those with poor follow-up reliability. 2

• PRP reduces the risk of progression to high-risk PDR 1
• Scatter photocoagulation should not be delayed once severe NPDR is identified 1

Proliferative Diabetic Retinopathy (PDR)

Panretinal laser photocoagulation remains the mainstay treatment for PDR, reducing the risk of severe vision loss from 15.9% to 6.4%. 2, 4

However, anti-VEGF therapy (ranibizumab, aflibercept, or faricimab) is now considered equally effective or superior to PRP for PDR. 4, 5, 6

• Anti-VEGF agents effectively regress proliferative disease with noninferior or superior visual acuity outcomes compared to PRP over 2 years 4
• Anti-VEGF therapy results in less peripheral visual field loss, fewer vitrectomy surgeries, and lower risk of developing diabetic macular edema compared to PRP 4
• Important caveat: Anti-VEGF therapy requires more frequent visits and treatments compared to PRP 4
• Follow-up should occur within 1 month of PDR diagnosis 4

Diabetic Macular Edema (DME)

Anti-VEGF therapy (intravitreal injections) is first-line treatment for center-involved DME with vision loss. 2

Specific anti-VEGF agents with FDA approval:

• Ranibizumab 0.3 mg monthly: 34-45% of patients gained ≥15 letters at 24 months versus 12-18% with sham 5
• Aflibercept 2 mg: After 5 initial monthly injections, can be dosed every 8 weeks with maintained efficacy 6
• Most patients require near-monthly administration during the first 12 months, with fewer injections in subsequent years 2

Laser photocoagulation remains the preferred treatment for non-center-involved DME. 2

• Focal laser photocoagulation reduces the risk of vision doubling (e.g., 20/50 to 20/100) from 20% to 8% at 2 years in clinically significant macular edema 1

Intravitreal corticosteroids may also be considered as an alternative treatment option. 1

Screening and Referral Criteria

Type 1 diabetes: Initial dilated eye examination within 5 years after diabetes onset 2

Type 2 diabetes: Initial dilated eye examination at the time of diagnosis 2, 3

If no retinopathy is present and glycemia is well-controlled, examinations every 1-2 years may be considered; if any retinopathy is present, annual examinations are required. 2

Immediate referral to an experienced ophthalmologist is mandatory for: 1, 2

• Any level of macular edema
• Severe NPDR
• Any PDR

Special Populations

Pregnancy: Women with pre-existing diabetes who become pregnant require early examination and close monitoring throughout pregnancy, as pregnancy accelerates retinopathy progression. 2

Aspirin therapy: Retinopathy is NOT a contraindication to aspirin for cardioprotection—aspirin does not increase the risk of retinal hemorrhage. 1, 2, 3

Common Pitfalls to Avoid

• Delaying ophthalmology referral when macular edema or severe/proliferative retinopathy is present—this is the most critical error 2
• Rapid implementation of intensive glycemic management in patients with existing retinopathy causes early worsening 2, 3
• Discontinuing aspirin due to unfounded concerns about retinal hemorrhage 2, 3
• Inadequate follow-up of patients with existing retinopathy 2
• Focusing only on glycemic control while neglecting blood pressure and lipid management 2, 3
• Failing to coordinate care between multiple practitioners (primary care, endocrinology, ophthalmology) 1