Screening for Diabetes-related Eye Disease

Screening for Diabetic Eye Disease

A number of countries have published their own clinical guideline recommendations relating to screening and management of Diabetes-related Retinopathy in people with diabetes (Table 1). Specific recommendations vary between countries, often reflecting differences between healthcare system structure (e.g. private vs public) and levels of health care resources available (e.g. health care personnel, access to diagnostic equipment and treatments).

The two largest global ophthalmology and diabetes societies (the International Council of Ophthalmology [ICO] and the International Diabetes Federation [IDF]) have also published international guidelines for eyes affected by diabetes, which include specific recommendations for screening, diagnosis and treatment of DR (Table 2).

Table 1: Countries with national guidelines containing recommendations relating to screening of diabetes-related retinopathy

Country Guideline title and reference
Australia National Health and Medical Research Council (NHMRC) clinical guidelines. Diabetic retinopathy
Canada Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy.

Hooper P et al. Can J Ophthalmol. 2012 Apr;47(2 Suppl):S1-30, S31-54.

China Chinese Ophthalmological Society. Retinopathy Working Group: diagnosis and treatment guideline of diabetic retinopathy 

Chin J Ophthalmol 2014; 50:851–86 

Denmark Evidence-based Danish guidelines for screening of diabetic retinopathy.
Grauslund J et al. Acta Ophthalmol. 2018;96:763-769 [6]
France Recommendations of the ALFEDIAM (French Association for the Study of Diabetes and Metabolic Diseases) for the screening and surveillance of diabetic retinopathy.

Massin P et al. J Fr Ophtalmol. 1997;20(4):302-10.

Germany National guidelines for treatment of diabetic retinopathy: Second edition of the national guidelines for treatment of diabetic retinopathy
Ziemssen F et al. Ophthalmic Epidemiol. 2017;24(2):73-80.
Hong Kong Primary Care Office, Department of Health. Hong Kong reference framework for diabetes care for adults in primary care settings 
India VISION 2020: The Right To Sight India. Guidelines for diabetic eye care in India. 
Iran Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population.
Rajavi Z et al. J Ophthalmic Vis Res. 2016 Oct-Dec;11(4):394-414.
Japan Japanese Clinical Practice Guideline for Diabetes 2016.

Haneda M, et al. J Diabetes Investig. 2018; 9: 657–697.

Norway The Diabetes guide-lines of the Norwegian College of General Practitioners  (Available at:
New Zealand New Zealand Ministry of Health. Diabetic retinal screening, grading, monitoring and referral guidance.2016 
Malaysia Ministry of Health Malaysia. Screening of diabetic retinopathy.
Philippines Unite for Diabetes Philippines. Philippine practice guidelines for the diagnosis and management of diabetes: part 1- screening & diagnosis. 
Republic of Ireland Republic of Ireland Diabetic Eye Screening Service
Singapore Ministry of Health Singapore. Diabetes mellitus: MOH clinical practice guidelines 2014 
Spain Update on Diagnosis and Treatment of Diabetic Retinopathy: A Consensus Guideline of the Working Group of Ocular Health (Spanish Society of Diabetes and Spanish Vitreous and Retina Society).
Corcóstegui B et al. J Ophthalmol. 2017;2017:8234186.
United States American Diabetes Association

American Academy® of Ophthalmology

United Kingdom National Institute for Clinical Excellence (2002) Management of type 2 diabetes, retinopathy – screening and early management. NICE Inherited Clinical Guideline E. London: National Institute for Clinical Excellence. Available from

Table 2: International guidelines for screening, treatment and management of diabetic eye disease 

International Diabetes Federation and The Fred Hollows Foundation. Diabetes eye health:
A guide for health care professionals
2018 International Council of Ophthalmology Guidelines on Diabetic Eye Care – The International Council of Ophthalmology Recommendations for Screening, Follow-up, Referral, and Treatment Based on Resource Settings

A short summary of the ICO and IDF global recommendations relating to screening and referral is provided below: Algorithms detailing the screening recommendations from the ICO and IDF guidelines are shown below (Figures 1 and 2). 

Figure 1: Flowchart showing screening for diabetic retinopathy (ICO Guidelines[7])

Figure 2: Screening recommendations (IDF/The Fred Hollows Foundation guidelines[8])

Who should perform the screening test?

Both the ICO and IDF guidelines both note that it may not be feasible / cost-effective for specialist eye physicians, such as ophthalmologists, to screen every person with diabetes. The ICO guidelines recommend that the screening vision examination can be performed by appropriately trained personnel, including general practitioner, nurse or other healthcare workers in the community setting. For the retinal examination, they recommend that the examiner must be well trained to perform ophthalmoscopy or retinal photography and be able to assess the severity of DR in retinal images (although a medical degree may not be necessary).