When should diabetic eye exams start for patients with type 1 and type 2 diabetes?

When to Start Diabetic Eye Exams

For type 2 diabetes, initiate a dilated comprehensive eye examination immediately at diagnosis; for type 1 diabetes, begin screening within 5 years after diagnosis. 1

Type 2 Diabetes: Immediate Screening at Diagnosis

Patients with type 2 diabetes require an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of diabetes diagnosis. 1 This immediate screening is critical because:

• Type 2 diabetes often remains undiagnosed for years, meaning patients may already have significant retinopathy at the time of clinical diagnosis 1
• The prevalence of existing retinopathy at diagnosis is substantial enough to warrant immediate evaluation 2
• Delaying the initial examination risks missing sight-threatening disease that is asymptomatic but already present 1

Type 1 Diabetes: Screening Within 5 Years

Adults with type 1 diabetes should have their initial dilated and comprehensive eye examination within 5 years after diabetes onset. 1 The rationale for this delayed timeline includes:

• Diabetic retinopathy requires at least 5 years of hyperglycemia to develop after the onset of type 1 diabetes 1
• For pediatric patients with type 1 diabetes, screening generally begins at age 10 years or older, though clinical judgment should guide individual cases 3
• The predictable timeline of retinopathy development in type 1 diabetes allows for this more conservative approach 2

Pregnancy-Related Screening: Before Conception

Women with preexisting type 1 or type 2 diabetes planning pregnancy must receive a comprehensive eye examination before conception and in the first trimester. 1 This aggressive approach is warranted because:

• The prevalence of any diabetic retinopathy in early pregnancy among women with preexisting diabetes is 52.3%, with proliferative diabetic retinopathy present in 6.1% 1
• Pregnancy accelerates retinopathy progression, with new retinopathy developing in 15% of pregnancies and worsening occurring in 31% of cases with existing nonproliferative disease 1
• Sight-threatening progression from nonproliferative to proliferative retinopathy occurs in 6.3% of pregnancies 1
• These patients require monitoring every trimester and for 1 year postpartum based on retinopathy severity 1, 3

Important exception: Women who develop gestational diabetes do not require eye examinations during pregnancy, as they are not at increased risk for diabetic retinopathy. 1

Follow-Up Examination Schedule

After the initial examination, the frequency of subsequent screening depends on findings and glycemic control:

• Annual examinations are recommended for all patients with diabetes if no retinopathy is present and glycemic control is adequate 1
• Every 1-2 years may be considered only if there is no evidence of retinopathy from one or more annual exams AND glycemic indicators are within goal range 1
• At least annual examinations are mandatory if any level of diabetic retinopathy is present 1
• More frequent than annual examinations are required if retinopathy is progressing or sight-threatening 1

Critical Caveat: GLP-1 Receptor Agonist Therapy

Assess retinopathy status before intensifying glucose-lowering therapy with GLP-1 receptor agonists, as rapid A1C reductions can cause initial worsening of retinopathy. 1, 2 This is particularly important because:

• GLP-1 RAs are associated with increased risk of rapidly worsening diabetic retinopathy in randomized trials 2
• Patients with existing retinopathy may benefit from more frequent follow-up initially when starting these agents 1

Alternative Screening Modalities

Retinal photography with remote reading or FDA-approved artificial intelligence algorithms are appropriate screening strategies when access to eye care professionals is limited. 1 However:

• These programs must provide clear pathways for timely referral for comprehensive eye examination when abnormalities are detected 1
• In-person comprehensive examinations remain the gold standard and are required at least initially 1

Common Pitfall to Avoid

The most critical error is delaying the initial eye examination in type 2 diabetes patients. Unlike type 1 diabetes where a 5-year window is safe, type 2 diabetes requires immediate screening because the actual onset of hyperglycemia is unknown and retinopathy may already be present and progressing. 1