Comm Eye Health Vol. 24 No. 75 2011 pp 12 - 13. Published online 31 October 2011.

Diabetic retinopathy (DR): management and referral

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This diabetic retinopathy (DR) grading system is based on the International Council of Ophthalmology’s diabetic retinopathy and diabetic macular oedema disease severity scales (see Useful Resources). At whatever level you work, you must encourage everyone with diabetes to manage their blood sugar and blood pressure. Refer them to available services for help if they are not sure how to do this, or if their control is poor.

Diabetic retinopathy stage

No abnormalities.
No abnormalities.
Microaneurysms (small, round ‘dots’) and haemorrhages  (larger, uneven ‘blots’). An example of moderate non-proliferative DR
Microaneurysms (small, round ‘dots’) and haemorrhages (larger, uneven ‘blots’). An example of moderate non-proliferative DR
Cotton wool spots (white), haemorrhages, and microaneurysms. An example of severe non-proliferative DR
Cotton wool spots (white), haemorrhages, and microaneurysms. An example of severe non-proliferative DR

No diabetic retinopathy

Clinical signs: No abnormalities

What to do (screening/primary eye care): Encourage patient to come again in 12 months

What to do (retinal clinic): Review in 12 months

What you could say to your patients: Diabetes can affect the inside of your eyes at any time. It is important that you come back in twelve months so we can examine you again. This will help to prevent you losing vision or going blind.

Mild non-proliferative diabetic retinopathy

Clinical signs: Microaneurysms only

What to do (screening/primary eye care): Encourage patient to come again in 12 months

What to do (retinal clinic): Review in 12 months

What you could say to your patients: Your diabetes is affecting your eyes. At the moment your vision is good, but we must check your eyes in 12 months’ time to see if these changes are getting worse. If the damage becomes severe, we will need to treat your eyes to stop the diabetes affecting your sight.

Moderate non-proliferative diabetic retinopathy

Clinical signs: More than just microaneurysms but less than severe non-proliferative retinopathy

What to do (screening/primary eye care): Encourage patient to come again in 6-12 months

What to do (retinal clinic): Review in 6–12 months

What you could say to your patients: Your diabetes is damaging your eyes. At the moment your vision is good, but we must check your eyes in six months’ time as it is likely that these changes will get worse. If the damage becomes severe, we will need to treat your eyes to stop the diabetes affecting your sight. Unless you are treated promptly, you risk losing vision or going blind.

Severe non-proliferative diabetic retinopathy

Clinical signs: More than 20 haemorrhages in each quadrant; or venous beading in two quadrants; or intraretinal microvascular abnormalities (IRMA)

What to do (screening/primary eye care): Refer to retinal clinic. All patients with severe non-proliferative DR should be in the care of an ophthalmologist. The patient should be re-examined every six months

What to do (retinal clinic): Either review in 6 months, or consider pan-retinal laser, if follow-up unreliable

What you could say to your patients: Your diabetes has damaged your eyes quite severely, although your vision is still good. You are likely to need treatment soon to ensure that you don’t lose vision or go blind. We must check your eyes in six months’ time. However, if you think you may not be able to come then, we may treat your eyes now, so we can be sure you don’t lose vision later.

New vessels on the optic disc. An example of proliferative DR
New vessels on the optic disc. An example of proliferative DR
Exudates (bright yellow). An example of mild macular oedema
Exudates (bright yellow). An example of mild macular oedema
Exudates. An example of severe macular oedema
Exudates. An example of severe macular oedema

Proliferative diabetic retinopathy

Clinical signs: Any new vessels at the disc or elsewhere, vitreous/ pre-retinal haemorrhage

What to do (screening/primary eye care): Urgent referral to retinal clinic

What to do (retinal clinic): Pan-retinal laser / vitrectomy if vitreous haemorrhage or retinal detachment

What you could say to your patients: Your diabetes has damaged your eyes very severely. Although your vision may be good, you are at great risk of losing your sight over the next year. You need urgent treatment to save your sight. Treatment will not improve your eyesight, but should preserve the vision you have.

Macular oedema

Macular oedema absent

Clinical signs: No exudates or retinal thickening in posterior pole

What to do (screening/primary eye care): Review in 12 months

What to do (retinal clinic): Review in 12 months

What you could say to your patients: As for “No diabetic retinopathy” above.

Mild macular oedema

Clinical signs: Exudates or retinal thickening at posterior pole, >1dd from fovea

What to do (screening/primary eye care): Review in 6 months

What to do (retinal clinic): Review in 6 months

What you could say to your patients: Your diabetes is damaging your eyes. At the moment your vision is good, but we must check your eyes in six months’ time as it is likely that these changes will get worse. If the damage becomes severe, we will need to treat your eyes to stop the diabetes affecting your sight. Unless you are treated promptly, you risk losing vision or going blind.

Moderate macular oedema

Clinical signs: Exudates or retinal thickening at posterior pole, 1dd or less from fovea, but not affecting fovea

What to do (screening/primary eye care): Refer to retinal clinic. Encourage patient to manage their blood sugar
and blood pressure, and refer them to available services for help if they are not sure how to do this

What to do (retinal clinic): Laser treatment if clinically significant macular oedema (CSMO) Review in 6 months if no CSMO

What you could say to your patients: Your diabetes has damaged your eyes severely. Although your vision may be good at present, it is likely to get worse over the next year or two. You need laser treatment to stop your sight deteriorating. The treatment will not improve your eyesight, but should preserve the vision you have.

Severe macular oedema

Clinical signs: Exudates or retinal thickening affecting centre of fovea

What to do (screening/primary eye care): Refer to retinal clinic

What to do (retinal clinic): Laser treatment or intravitreal injections of anti-VEGF drugs

What you could say to your patients: You have probably noticed your eyesight has got worse. This is because your diabetes has damaged your eyes very severely. You need urgent treatment to prevent further loss of vision. The treatment may not improve your eyesight, but if you are not treated, your vision will get worse and you may even become blind.


If you cannot see the retina due to cataract or vitreous haemorrhage, refer to an ophthalmologist for cataract surgery or a retinal sugeon for vitrectomy.