Evidence from several randomised controlled trials showed that, for people with non-proliferative retinopathy, intensive blood glucose management brings long-term benefits (1):
- no studies evaluated the effects of a rapid, substantial reduction in HbA1c for people with proliferative retinopathy or macular oedema
Effects of a rapid reduction in HbA1c if diabetes retinopathy
- when starting a diabetes treatment that is likely to result in a rapid, substantial drop in the person's HbA1c, notify the person's ophthalmologist so they can assess the person's eyes before treatment begins and check for changes afterwards (1)
Ophthalmologists should consider fenofibrate for people with non-proliferative retinopathy and type 2 diabetes to reduce the progression (1).
Non-proliferative diabetic retinopathy (NPDR) Monitoring
If very severe or severe NPDR then monitor progression and consider seeing the person every 3 to 6 months
If very moderate NPDR then monitor progression and consider seeing the person every 6 to 12 months
Proliferative diabetic retinopathy (PDR) Management principles:
- panretinal photocoagulation should be offered when the person is first diagnosed with PDR
- anti-vascular endothelial growth factor medicines (anti-VEGFs) should be considered as a temporary solution if the person:
- has vitreous haemorrhage secondary to proliferative diabetic retinopathy which is preventing panretinal photocoagulation
- the patient needs cataract surgery and the severity of the cataract is preventing panretinal photocoagulation
- if incomplete panretinal photocoagulation then anti-VEGF should be offered - in August 2024, the only anti-VEGF treatment licensed for proliferative diabetic retinopathy was ranibizumab
Macular oedema management principles:
Treatment options:
- anti-VEGFs
- macular laser treatment
- steroid treatment
- observation
If centre involving macular oedema and visual impairment
- central retinal thickness of 400 micrometres or more: offer anti-VEGFs
- central retinal thickness of less than 400 micrometres: consider anti-VEGFs or macular laser
- if the person cannot have non-corticosteroid therapy, consider an intravitreal steroid implant
if centre-involving macular oedema with good vision then consider macular laser or observation or both
if non-centre involving clinical significant macular oedema (CSMO*) then macular laser treatment should be offered
- Clinically significant diabetic macular oedema
- diabetic macular oedema is clinically significant when any of the following signs are present, based on slit-lamp biomicroscopy with stereopsis:
- retinal thickening at or within 500 micrometres of the centre of the fovea
- hard exudation at or within 500 micrometres of the centre of the fovea with adjacent retinal thickening
- retinal thickening of 1 disc area or more within 1 disc area of the centre of the fovea
Reference:
- NICE (August 2024). Diabetic retinopathy: management and monitoring