What is the best approach to manage diabetic retinopathy in a patient with a history of diabetes, considering the condition of their retina?

Management of Diabetic Retinopathy Based on Retinal Examination Findings

The management of diabetic retinopathy must be stratified based on the severity of retinal findings, with immediate ophthalmology referral for any macular edema, severe nonproliferative diabetic retinopathy, or proliferative diabetic retinopathy, while simultaneously optimizing systemic risk factors including glycemic control, blood pressure, and lipid management. 1

Systemic Risk Factor Optimization (Foundation for All Patients)

Regardless of retinal findings, aggressive systemic management is essential:

• Optimize glycemic control to reduce risk and slow progression of diabetic retinopathy 1
• Target blood pressure <130/80 mmHg to slow retinopathy progression 1, 2
• Optimize serum lipid control to reduce risk and slow progression 1
• Aspirin therapy for cardioprotection is NOT contraindicated in patients with retinopathy, as it does not increase risk of retinal hemorrhage 1

Algorithm Based on Retinal Examination Findings

No Retinopathy with Good Glycemic Control

• Continue annual dilated examinations by ophthalmologist or optometrist 1, 3
• May extend to every 1-2 years if no retinopathy for one or more annual exams and glycemia is well controlled 1
• Continue systemic risk factor optimization 1

Mild to Moderate Nonproliferative Diabetic Retinopathy

• Repeat dilated retinal examinations at least annually 1
• More frequent examinations if retinopathy is progressing 1, 3
• Intensify systemic risk factor management 1
• No immediate laser or intravitreal therapy required unless macular edema develops 1

Severe Nonproliferative Diabetic Retinopathy

• Immediate referral to ophthalmologist experienced in diabetic retinopathy management 1
• Do NOT delay referral until proliferative disease develops, as early treatment reduces vision loss risk by 50% 1, 3
• Panretinal laser photocoagulation may be indicated in some cases to prevent progression 1
• Consider anti-VEGF therapy as alternative to laser 1

Proliferative Diabetic Retinopathy

• Immediate referral to experienced ophthalmologist 1
• Panretinal laser photocoagulation is standard treatment to reduce risk of severe vision loss from 15.9% to 6.4% 1
• Intravitreous anti-VEGF injections (ranibizumab) are not inferior to traditional panretinal laser photocoagulation and are also indicated 1, 4
• Monthly monitoring recommended for first 3-6 months if on anti-VEGF therapy 2

Any Level of Macular Edema

• Immediate referral to experienced ophthalmologist 1, 2
• Intravitreous anti-VEGF injections are first-line treatment for central-involved diabetic macular edema that impairs vision 1, 4
• Most patients require near-monthly anti-VEGF injections during first 12 months, with fewer injections in subsequent years 1
• For central-involved macular edema with moderate visual impairment, aflibercept provides superior vision outcomes compared to bevacizumab 1
• Focal laser photocoagulation is less effective than anti-VEGF monotherapy for center-involved macular edema 1

Special Monitoring Situations

Patients on Rapid Glycemic Improvement (e.g., Retatrutide)

• Pre-treatment dilated comprehensive eye examination required including visual acuity, slit-lamp biomicroscopy, intraocular pressure, stereoscopic posterior pole examination, and indirect ophthalmoscopy 2
• Patients with pre-existing retinopathy require visits every 3 months during first year, particularly if HbA1c drops >1.5% in 3 months 2
• Moderate nonproliferative retinopathy: monitor every 3-6 months 2
• Severe nonproliferative or proliferative retinopathy: monthly monitoring for first 3-6 months 2

Pregnancy with Pre-existing Diabetes

• Comprehensive eye examination before pregnancy or in first trimester 1, 3
• Monitor every trimester and for 1 year postpartum based on retinopathy severity 1, 3
• Pregnancy can rapidly aggravate retinopathy, especially with poor glycemic control at conception 1
• Gestational diabetes does NOT require special retinal screening 3

Critical Patient Education Points

Educate patients to report immediately:

• New floaters or flashing lights 2
• Dark spots in central vision 2
• Any sudden vision changes 2

Common Pitfalls to Avoid

• Never delay referral waiting for proliferative disease to develop in patients with severe nonproliferative retinopathy—early treatment significantly reduces vision loss risk 1, 3
• Do not assume aspirin is contraindicated in patients with retinopathy; cardioprotection benefits outweigh any theoretical bleeding risk 1
• Do not rely solely on focal laser for center-involved macular edema; anti-VEGF therapy is superior 1
• Do not underestimate pregnancy risk in patients with pre-existing diabetes; rapid progression can occur without proper monitoring 1