ICO International Clinical Guidelines:

Diabetic Retinopathy (Management Recommendations)

(Download this Guideline as a PDF file - 95 KB)

Management Recommendations for Patients with Diabetes

Severity of Retinopathy	Presence of CSME*	Follow-up (Months)	Panretinal Photocoagulation (Scatter) Laser	Fluorescein Angiography	Focal and/or Grid Laser†
1. Normal or minimal NPDR	No	12	No	No	No
2. Mild to moderate NPDR	No Yes	6-12 2-4	No No	No Usually	No Usually*^
3. Severe NPDR	No Yes	2-4 2-4	Sometimes‡ Sometimes‡	Rarely Usually	No Usually**
4. Non-high-risk PDR	No Yes	2-4 2-4	Sometimes‡ Sometimes‡	Rarely Usually	No Usually^
5. High-risk PDR	No Yes	2-4 2-4	Usually Usually	Rarely Usually	No Usually**
6. Inactive/ involuted PDR	No Yes	6-12 2-4	No No	No Usually	Usually Usually

* Exceptions include: hypertension or fluid retention associated with heart failure, renal failure, pregnancy, or any other causes that may aggravate macular edema. Deferral of photocoagulation for a brief period of medical treatment may be considered in these cases. Also, deferral of CSME treatment is an option when the center of the macula is not involved, visual acuity is excellent, and the patient understands the risks.

† Adjunctive treatments that may be considered include intravitreal corticosteroids or anti-vascular endothelial growth factor agents (off-label use).

^ Deferring focal photocoagulation for CSME is an option when the center of the macula is not involved, visual acuity is excellent, close follow-up is possible, and the patient understands the risks. However, initiation of treatment with focal photocoagulation should also be considered because although treatment with focal photocoagulation is less likely to improve the vision, it is more likely to stabilize the current visual acuity. Treatment of lesions close to the foveal avascular zone may result in damage to central vision and with time, such laser scars may expand and cause further vision deterioration. Closer follow-up may be necessary for macular edema that is not clinically significant.

‡ Panretinal photocoagulation surgery may be considered as patients approach high-risk PDR. The benefit of early panretinal photocoagulation at the severe nonproliferative or worse stage of retinopathy is greater in patients with Type 2 diabetes than in those with Type 1. Treatment should be considered for patients with severe NPDR and Type 2 diabetes. Other factors, such as poor compliance with follow-up, impending cataract extraction or pregnancy, and status of fellow eye will help in determining the timing of the panretinal photocoagulation.

** It is preferable to perform the focal photocoagulation first, prior to panretinal photocoagulation, to minimize panretinal photocoagulation laser-induced exacerbation of the macular edema.

CSME = clinically significant macular edema; NPDR = nonproliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy

* Adapted from the American Academy of Ophthalmology Summary Benchmarks, November 2008 (www.aao.org)

(Download this Guideline as a PDF file - 95 KB)

Next: Esotropia (Initial and follow-up evaluation)

Also see:

• International Clinical Guidelines (Preface)
  
  
• Introduction to the Guidelines
  
  
• List of Guidelines