People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
All clinicians involved in caring for people with diabetic retinopathy (including macular oedema) should discuss with them how good long-term management of their diabetes can have long-term benefits for their vision. Refer to NICE's guidelines on managing type 1 diabetes in adults, managing type 2 diabetes in adults and diagnosing and managing diabetes (type 1 and type 2) in children and young people to support this discussion.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on working with the person.
Full details of the evidence and the committee's discussion are in evidence review C: effectiveness of intensive treatments to lower blood glucose levels.
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.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on effects of a rapid reduction in HbA1c.
Full details of the evidence and the committee's discussion are in evidence review C: effectiveness of intensive treatments to lower blood glucose levels.
Ophthalmologists should:
have access to a person's HbA1c and blood pressure results
discuss them with the person and
explain to them how lowering these results could reduce the risk of their eye condition progressing to proliferative diabetic retinopathy or diabetic macular oedema.
When making decisions with someone about ophthalmic interventions and frequency of follow-up appointments, take into account their:
stage of diabetic retinopathy
HbA1c level
renal function and
blood pressure.
Provide healthcare professionals involved in diabetes care with information about the severity of a person's diabetic eye disease so it can be taken into account in decisions about their overall diabetes management.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information that should be available to all people involved in the care of people with diabetic retinopathy.
Full details of the evidence and the committee's discussion are in evidence review A: prognostic factors for progression of non-proliferative diabetic retinopathy.
Refer to NICE's guideline on hypertension for recommendations on blood pressure management for adults with diabetes and hypertension.
Be aware that, for people with hypertension, managing blood pressure can reduce progression of non-proliferative diabetic retinopathy.
Do not offer blood pressure management medicines to people without hypertension for the sole purpose of preventing the progression of non-proliferative diabetic retinopathy.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on blood pressure management.
Full details of the evidence and the committee's discussion are in evidence review D: effectiveness of lipid modification therapies and antihypertensive medicines.
Ophthalmologists should consider fenofibrate for people with non-proliferative retinopathy and type 2 diabetes to reduce the progression of diabetic retinopathy.
In August 2024, this was an off-label use of fenofibrate. See NICE's information on prescribing medicines.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on fenofibrate.
Full details of the evidence and the committee's discussion are in evidence review D: effectiveness of lipid modification therapies and antihypertensive medicines.
NICE has made a recommendation for research about statins to prevent progression of non-proliferative retinopathy and diabetic macular oedema.
For a short explanation of why the committee made no recommendations, see the rationale and impact section on statins.
Full details of the evidence and the committee's discussion are in evidence review D: effectiveness of lipid modification therapies and antihypertensive medicines.
Before cataract surgery for a person with diabetes, the surgeon should obtain information about the person's current diabetic eye disease status. The surgeon can then use this information to tailor the surgery, post-operation medication and follow-up to the person's condition and needs.
For guidance on managing cystoid macular oedema as a complication of cataract surgery in people with diabetes, see the section on preventing and managing complications in NICE's guideline on managing cataracts in adults.
Also see recommendation 1.5.6 on anti-vascular endothelial growth factor (anti-VEGF) treatment as a temporary solution for people with proliferative diabetic retinopathy who need cataract surgery.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on cataract surgery.
Full details of the evidence and the committee's discussion are in evidence review I: treatments before, during or after cataract surgery.
After assessing eyes with diabetic retinopathy, treat and monitor each eye separately based on the eye's active pathologies. Depending on the eye's stage of retinopathy, see the recommendations on:
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on treating all active pathologies in each eye.
Full details of the evidence and the committee's discussion are in evidence review G: effectiveness and acceptability of intravitreal steroids, macular laser and anti-VEGFs for treating diabetic macular oedema.
For guidance on monitoring diabetic retinopathy during pregnancy, see the section on retinal assessment during pregnancy in NICE's guideline on diabetes in pregnancy.
Hospital eye services should monitor disease progression in people with moderate, severe or very severe non-proliferative retinopathy who are not currently having treatment and have not previously had treatment. Consider seeing them:
every 6 to 12 months if they have moderate non-proliferative diabetic retinopathy
every 3 to 6 months if they have severe or very severe non-proliferative retinopathy.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on when to assess disease status and how often to monitor.
Full details of the evidence and the committee's discussion are in evidence review J: effectiveness of different monitoring frequencies.
Discuss with the person with proliferative diabetic retinopathy the benefits and potential side effects of each of the following 3 options: panretinal photocoagulation, anti-vascular endothelial growth factor medicines (anti-VEGFs), and no treatment (observation). As part of this discussion, explain:
what proliferative diabetic retinopathy is, and whether they have high-risk characteristics
that panretinal photocoagulation is usually the first treatment for most people with proliferative diabetic retinopathy
which treatment is likely to work best for them.
Follow the recommendations on communication and information in NICE's guidelines on patient experience in adult NHS services, babies, children and young people's experience of healthcare, and shared decision making.
Offer panretinal photocoagulation to people when they are first diagnosed with proliferative diabetic retinopathy.
Use the following timeframes for panretinal photocoagulation:
Start treatment within 4 weeks of offering, if possible.
If it cannot be started within 4 weeks, start it within 6 weeks of offering.
Complete it within 4 weeks of starting treatment.
For people with high-risk characteristics or who have difficulty attending appointments, offer to start panretinal photocoagulation on the same day. For example, offer this to people who have neovascularisation which meets the criteria for high-risk characteristics, or those who have difficulty accessing transport to be able to attend hospital appointments.
Offer anti-VEGF treatment for people whose proliferative diabetic retinopathy remains active after complete panretinal photocoagulation and discuss the advantages and disadvantages of the available anti-VEGFs with the person.
If the person has vitreoretinal traction or tractional retinal detachment, monitor them closely in collaboration with a vitreoretinal specialist (see also the section on vitrectomy for people with proliferative diabetic retinopathy).
In August 2024, the only anti-VEGF treatment licensed for proliferative diabetic retinopathy was ranibizumab and use of any other anti-VEGF treatment would be off-label. See NICE's information on prescribing medicines.
Consider anti-VEGF treatment as a temporary treatment for people with proliferative diabetic retinopathy who:
have vitreous haemorrhage secondary to proliferative diabetic retinopathy that is preventing panretinal photocoagulation (see also the section on vitrectomy for proliferative diabetic retinopathy)
need cataract surgery and the severity of the cataract is preventing panretinal photocoagulation (see also the section on cataract surgery for people with diabetic retinopathy or diabetic macular oedema).
Discuss the advantages and disadvantages of the available anti-VEGFs with the person.
If the person has vitreoretinal traction or tractional retinal detachment, monitor them closely in collaboration with a vitreoretinal specialist.
In August 2024, the only anti-VEGF treatment licensed for proliferative diabetic retinopathy was ranibizumab, and use of any other anti-VEGF treatment would be off-label. See NICE's information on prescribing medicines.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatment strategies for non-proliferative and proliferative diabetic retinopathy.
Full details of the evidence and the committee's discussion are in:
Consider vitrectomy for people with proliferative diabetic retinopathy and vitreous haemorrhage that has not cleared within 3 months (often called 'non-clearing vitreous haemorrhage' in clinical practice). Perform vitrectomy within 3 months of offering it.
Offer vitrectomy to people with proliferative diabetic retinopathy and macula-involving or macula-threatening retinal detachment.
Consider vitrectomy for people with non-macula-involving or non-macula-threatening retinal detachment who, despite complete panretinal photocoagulation, have:
proliferative diabetic retinopathy that is active or
recurring vitreous haemorrhages related to active proliferative diabetic retinopathy or vitreomacular traction.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on vitrectomy.
Full details of the evidence and the committee's discussion are in:
Consider using ultrawide-field fundus imaging alongside clinical examination when assessing eyes for the presence of proliferative diabetic retinopathy.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on imaging techniques for monitoring diabetic retinopathy and diabetic macular oedema.
Full details of the evidence and the committee's discussion are in evidence review K: diagnostic accuracy of ultrawide-field fundus photography and optical coherence tomography.
For guidance on monitoring proliferative diabetic retinopathy during pregnancy, see the section on retinal assessment during pregnancy in NICE's guideline on diabetes in pregnancy.
Assess disease regression in people who have received treatment for proliferative diabetic retinopathy. Conduct this assessment 2 to 3 months after the end of treatment (see recommendation 1.5.10 on imaging techniques for proliferative diabetic retinopathy).
For people whose disease has regressed after treatment for proliferative diabetic retinopathy, monitor under the care of hospital eye services for 12 months after the end of treatment, using an individualised monitoring frequency.
For people whose disease has regressed after treatment for proliferative diabetic retinopathy, after the first 12 months following the end of treatment:
Discharge the person to the diabetic eye screening programme if they are eligible for it (see Public Health England's criteria for referral to the diabetic eye screening programme).
If the person's retina has features that makes it ineligible for the screening programme, monitor the person's eyes under the care of hospital eye services, and consider seeing them every 12 months (see recommendation 1.5.10 on imaging techniques for proliferative diabetic retinopathy).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on when to assess disease status and how often to monitor.
Full details of the evidence and the committee's discussion are in evidence review J: effectiveness of different monitoring frequencies.
For people whose disease has not regressed after treatment for proliferative diabetic retinopathy, see recommendations 1.5.1 to 1.5.6 on treatment strategies for proliferative diabetic retinopathy.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on treatment strategies for non-proliferative and proliferative diabetic retinopathy.
Full details of the evidence and the committee's discussion are in:
Offer treatment to people with clinically significant macular oedema (centre-involving and non-centre-involving).
Discuss with the person with clinically significant macular oedema the benefits and potential side effects of:
anti-VEGF treatment
macular laser treatment
steroid treatment
observation.
As part of this discussion, tell them whether they have centre-involving or non-centre-involving macular oedema, and which treatment is likely to work best for their particular condition.
Follow the recommendations on communication and information in NICE's guidelines on patient experience in adult NHS services, babies, children and young people's experience of healthcare, and shared decision making.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on discussing and offering treatment for diabetic macular oedema.
Full details of the evidence and the committee's discussion are in evidence review G: effectiveness and acceptability of intravitreal steroids, macular laser and anti-VEGFs for treating diabetic macular oedema.
Offer macular laser treatment to people with non-centre-involving clinically significant macular oedema.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on treatment strategies for non-centre-involving diabetic macular oedema.
Full details of the evidence and the committee's discussion are in:
For people with centre-involving diabetic macular oedema and good vision (79 letters or better) consider either macular laser treatment or observation. Discuss these 2 options with the person with macular oedema.
For people with centre-involving diabetic macular oedema, visual impairment and central retinal thickness of 400 micrometres or more, offer anti-VEGF treatment. Discuss with the person the advantages and disadvantages of the available anti-VEGFs.
In August 2024, NICE technology appraisal guidance recommended ranibizumab, brolucizumab, faricimab and aflibercept as options for treating visual impairment in eyes with central retinal thickness of 400 micrometres or more (see NICE technology appraisal guidance on anti-VEGFs for visual impairment caused by diabetic macular oedema). At that time, these were the only anti-VEGF treatments licensed for visual impairment caused by diabetic macular oedema. Use of any other anti-VEGF treatment would be off-label (see NICE's information on prescribing medicines).
For people with centre-involving diabetic macular oedema, visual impairment and central retinal thickness of less than 400 micrometres, consider anti-VEGF or macular laser treatment. Discuss with the person the advantages and disadvantages of all available treatments.
In August 2024, anti-VEGF treatments licensed for visual impairment due to diabetic macular oedema were ranibizumab, brolucizumab, faricimab and aflibercept. Use of any other anti-VEGF treatment would be off-label (see NICE's information on prescribing medicines).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatment strategies for centre-involving diabetic macular oedema.
Full details of the evidence and the committee's discussion are in:
For anti-VEGFs recommended as options in NICE technology appraisal guidance for treating visual impairment caused by diabetic macular oedema, see the guidance on:
After the loading phase, assess response to anti-VEGF treatment. Consider using macular laser as adjuvant treatment if the response is suboptimal.
Twelve months after starting anti-VEGF treatment, assess response to treatment. Consider switching to an intravitreal steroid implant if the response is suboptimal.
At any time after the start of treatment, if a person does not want to continue with regular anti-VEGF injections, consider switching treatment to an intravitreal steroid implant.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on when to add, switch or stop treatment.
Full details of the evidence and the committee's discussion are in evidence review H: clinical features for switching or stopping treatment.
When people with centre-involving diabetic macular oedema have visual impairment and cannot have non-corticosteroid therapy, consider an intravitreal steroid implant.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on when non-corticosteroid treatment is not possible.
Full details of the evidence and the committee's discussion are in:
For intravitreal steroid implants recommended as options in NICE technology appraisal guidance for treating visual impairment caused by diabetic macular oedema, see the guidance on:
Use optical coherence tomography (OCT) imaging when assessing someone's eyes for the presence of diabetic macular oedema.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on imaging techniques for monitoring diabetic retinopathy and diabetic macular oedema.
Full details of the evidence and the committee's discussion are in evidence review K: diagnostic accuracy of ultrawide-field fundus photography and optical coherence tomography.
For people whose disease has resolved after treatment for diabetic macular oedema, monitor under the care of hospital eye services for the first 12 months after the end of treatment, using an individualised monitoring frequency.
For people whose disease has resolved after treatment for diabetic macular oedema, after the first 12 months following the end of treatment:
Discharge the person to the diabetic eye screening programme if they are eligible for it (see Public Health England's criteria for referral to the diabetic eye screening programme).
If the person's retina has features that makes it ineligible for the screening programme, monitor them under the care of hospital eye services, and consider seeing the person every 12 months.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on when to assess disease status and how often to monitor.
Full details of the evidence and the committee's discussion are in evidence review J: effectiveness of different monitoring frequencies.
For people with diabetic macular oedema that does not respond to anti-VEGF treatment and also have either vitreomacular traction or epiretinal membrane:
check for warning signs of permanent damage and
consider vitrectomy before any permanent damage occurs.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on vitrectomy.
Full details of the evidence and the committee's discussion are in:
For people whose disease has not resolved after treatment for diabetic macular oedema, see recommendations 1.6.1 to 1.6.14 on treatment strategies for diabetic macular oedema.
This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.
Diabetic macular oedema that involves the central subfield of the Early Treatment Diabetic Retinopathy Studies (ETDRS) grid, which has a diameter of 1 mm. Centre-involving diabetic macular oedema is always clinically significant.
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.
Clinically significant diabetic macular oedema that does not involve the central subfield of the Early Treatment Diabetic Retinopathy Studies (ETDRS) grid, which has a diameter of 1 mm.
Panretinal photocoagulation is complete when:
all of the midperipheral retina and peripheral retina (from 2-disc diameters away from the fovea to the equator) has been treated with panretinal photocoagulation, leaving one-size burn space in between burns and
for people whose proliferative diabetic retinopathy had remained active after this original treatment, additional 'fill-in' laser has been applied, if appropriate, adding burns in the spaces left by the original treatment.
Retinopathy includes non-proliferative retinopathy, proliferative retinopathy and maculopathy.
Proliferative diabetic retinopathy regression is defined by:
regression or disappearance of new vessels as seen on fundus examination or fundus imaging, or fluorescein angiography
fibrosis developing in areas of new vessels
absence of new vitreous or preretinal haemorrhages.
Progression of diabetic retinopathy as a result of a rapid, substantial drop in a person's HbA1c from diabetes treatments or other causes, such as pancreas transplant.
High-risk proliferative diabetic retinopathy as defined by the Early Treatment Diabetic Retinopathy Studies (ETDRS) is characterised by neovascularisation:
either on or within one disc diameter of the optic disc, greater than one-fourth to one-third disc area in size
elsewhere in the retina, greater than one-half a disc area in size, with a preretinal haemorrhage or vitreous haemorrhage
of any optic disc, with a vitreous or preretinal haemorrhage.
The use of macular laser in addition to anti-vascular endothelial growth factor (anti-VEGF) treatment when, following the loading phase, a person's eye has had a suboptimal response to anti-VEGF treatment alone.
Damage such as photoreceptor cell loss, macular atrophy or lamellar macular holes. The time that it takes for permanent damage to occur can vary between people.
Presence of isolated or sparse, small, intraretinal cysts with no other features as seen from optical coherence tomography (OCT) scans.
Treatment response for diabetic macular oedema is suboptimal if there is:
reduced vision as a result of diabetic macular oedema or
increased diabetic macular oedema or
no change, or increase, in retinal thickness related to diabetic macular oedema.
78 ETDRS letters or less, or a Snellen acuity of 6/9 or worse.