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Diabetic Retinopathy

NICE guideline [NG242] Diabetic retinopathy: management and monitoring. Published Aug 2024.

Background Information

In the UK, diabetic retinopathy is graded according to the NHS DESPDiabetic Eye Screening Programme classification.

This is a summary of the classification, see below for the full classification and grading:
Type of retinopathy Subtype Findings
Diabetic retinopathy Background retinopathy
  • Microaneurysms
  • Retinal haemorrhages
  • Hard exudates
  • Cotton wool spots
Pro-proliferative retinopathy
  • Venous beading
  • Multiple blot haemorrhages
  • Intraretinal microvascular abnormalities (IRMAs)
Proliferative retinopathy Characterised by new:
  • Vessels on disc / elsewhere
  • Vitreous haemorrhage
  • Tractional retinal detachment
Diabetic maculopathy Any changes above within 1 disc diameter of the centre of the fovea

Gudielines

No specific treatment indicated:
  • Optimise blood glucose control
 
  • Monitor progression via hospital eye services
    • If moderate → every 6-12 months
    • If severe / very severe → every 3-6months

1st line: offer panretinal laser photocoagulation to ALL patients
  • Start within 4 weeks of offering

If ineffective → anti-VEGFAnti-vascular endothelial growth factor (ranibizumab)
 

  • Offer if there is proliferative diabetic retinopathy AND retinal detachment involving or threatening the macula
  • Consider if there is non-clearing vitreous haemorrhage (>3 months)
  • Consider if there is retinal detachment AND proliferative diabetic retinopathy remains active after photocoagulation OR recurring vitreous haemorrhage related to proliferative diabetic retinopathy

Consider using ultrawide-field fundus imaging alongside clinical examination

Monitoring timing and frequency:
  • 2-3 months after the end of treatment
  • If retinopathy regressed after treatment → monitor for another 12 months (individualised frequency) → discharge to diabetic eye screening programme (if eligible, or else 12 monthly review)

Treatment is only indicated if there is  clinically significant macular oedema (CSMO)

Treatment options:
  • 1st line: non-corticosteroid therapy
    • Macular laser treatment
    • Anti-VEGFAnti-vascular endothelial growth factor (ranibizumab)
  • 2nd line: intravitreal steroid implant (dexamethasone / flucinolone acetonide)
  • Last resort: consider vitrectomy if did not respond to anti-VEGF AND have vitreomacular traction / epiretinal membrane
 

Location Vision Treatment
Non-centre involving n/a Macular laser treatment
Centre-involving Good  Observation OR macular laser treatment
Impaired (6/9 or worse) Anti-VEGF OR macular laser treatment

*If central retinal thickness ≥400 → anti-VEGF is preferred

Use OCTOptical coherence tomography to assess diseae resolution and monitoring.

Monitoring timing and frequency:
  • If maculopathy resolved after treatment → monitor for another 12 months (individualised frequency) → discharge to diabetic eye screening programme (if eligible, or else 12 monthly review)

References

Author: Adams Lau
Reviewer: 
Last edited: 08/05/25