Diabetic retinopathy: screening and prevention in Australian general practice

Retinopathy, diabetes, and the risk of preventable blindness

Diabetic retinopathy (DR) is the most common microvascular complication of diabetes. Chronically elevated blood glucose damages the fine blood vessels of the retina — the light-sensitive lining of the eye — causing progressive changes that, if untreated, can lead to severe vision loss and blindness. It is the leading cause of preventable blindness in working-age Australians aged 20 to 64.

Approximately 1.5 million Australians live with diagnosed diabetes; a further estimated 500,000 cases are undiagnosed. Around 30% of people with diabetes have some form of diabetic retinopathy; approximately 5% have sight-threatening disease. The “preventable” qualifier is critical — early detection through annual screening allows treatment to be applied at a stage when vision can be protected, before symptoms appear.

Diabetic macular oedema (DMO) is the most common cause of vision loss in diabetic retinopathy, occurring when fluid accumulates in the macula (the region responsible for central, detailed vision). Proliferative diabetic retinopathy (PDR) — where abnormal new blood vessels grow — carries the risk of vitreous haemorrhage, tractional retinal detachment, and neovascular glaucoma.

The GP’s role is foundational: organising and tracking annual screening, optimising modifiable systemic risk factors, and knowing when urgent specialist referral is needed.

A. Core clinical — the AU general-practice framework

Who to screen and when

Type 2 diabetes:
Retinal screening is recommended from the time of diagnosis, per RACGP Management of Type 2 Diabetes and RANZCO Diabetic Retinopathy Guidelines. Approximately 20% of people with type 2 diabetes already have retinopathy at the time of diagnosis due to delayed identification of hyperglycaemia. After the baseline screen: every one to two years if no retinopathy is found; annually if any retinopathy is present; more frequently if progressing.

Type 1 diabetes:
Screening from five years after diagnosis in adolescents and adults. For children diagnosed before puberty, screening commences at the onset of puberty. Type 1 DR develops over years and is nearly universal at 20 years’ disease duration.

Pregnancy (pre-existing type 1 or type 2 diabetes):
Eye review before conception (or as early as possible in early pregnancy), at each trimester, and six to twelve weeks postpartum. Diabetic retinopathy can progress rapidly during pregnancy, including paradoxical early worsening with intensification of glycaemic control. Gestational diabetes does not routinely require retinal screening unless overt diabetes is identified at the time.

How to screen

Non-mydriatic retinal photography is practical in general practice, does not require dilation, and is funded under MBS item 12325 — once every 24 months for people with diabetes (or more frequently where indicated by current MBS rules). The GP or trained practice nurse performs the photography; images require interpretation by an accredited reader.

Mydriatic retinal photography or dilated fundus examination by an ophthalmologist or therapeutic-endorsed optometrist remains the gold standard, particularly when non-mydriatic images are of insufficient quality or when peripheral pathology is suspected.

Optical coherence tomography (OCT) is required to confirm and grade diabetic macular oedema. It is performed in specialist ophthalmology or optometry practices and provides cross-sectional imaging of retinal layers and fluid.

Classification of diabetic retinopathy

The internationally used staging system covers a spectrum from no retinopathy to proliferative disease:

Stage	Key features
No DR	No abnormalities on retinal imaging
Mild NPDR	Microaneurysms only
Moderate NPDR	Dot and blot haemorrhages, hard exudates, cotton-wool spots
Severe NPDR	”4-2-1 rule” — diffuse haemorrhages in 4 quadrants, venous beading in 2 quadrants, or IRMA in 1 quadrant
Proliferative DR (PDR)	Neovascularisation of disc or elsewhere; preretinal or vitreous haemorrhage; tractional detachment
Diabetic macular oedema	Centre-involving or non-centre-involving; confirmed by OCT

Referral thresholds

• No DR: continue annual screening; reinforce systemic risk-factor management
• Mild NPDR: screening every 6–12 months; optometry or ophthalmology depending on local services and access
• Moderate or severe NPDR: ophthalmology referral within 2–3 months
• Proliferative DR: urgent ophthalmology referral within weeks
• Centre-involving DMO with visual threat: ophthalmology referral within weeks (sooner if rapid change)
• Sudden vision loss (vitreous haemorrhage, retinal detachment, CRAO): same-day ophthalmology or emergency department

The systemic risk factors the GP controls

Blood sugar, blood pressure, lipids, and smoking are the four most powerful modifiable determinants of diabetic retinopathy progression — and all are managed in general practice:

Glycaemic control: The DCCT (type 1 diabetes) demonstrated a 76% reduction in development of diabetic retinopathy with intensive glycaemic control; UKPDS 33 (type 2 diabetes) demonstrated a 25% reduction in microvascular endpoints. Target HbA1c ~7% (53 mmol/mol), individualised. Caution: rapid reduction of a long-standing very high HbA1c (e.g., starting insulin or a GLP-1 agonist in a patient with HbA1c > 10%) can cause paradoxical early worsening of retinopathy — co-manage with ophthalmology if rapid intensification is planned.

Blood pressure: Target < 130/80 mmHg in diabetes with end-organ disease, per RACGP and National Heart Foundation guidelines. ACE inhibitor or ARB first-line, particularly if albuminuria is present.

Lipids and fenofibrate: Statins are recommended per cardiovascular risk guidelines. Fenofibrate — studied in the FIELD and ACCORD-Eye trials — reduced the need for laser treatment and DR progression by approximately 30% in type 2 diabetes, with an effect that appears independent of its lipid-lowering action. Fenofibrate is available on the PBS for hypertriglyceridaemia; its use in DR is considered in people with type 2 diabetes and established retinopathy, particularly in the presence of hypertriglyceridaemia. Refer to eTG for prescribing guidance.

Smoking cessation: Smoking accelerates all diabetic microvascular complications. Cessation support — varenicline (PBS Authority), bupropion (PBS), nicotine replacement therapy, and behavioural counselling — should be offered at every opportunity.

B. Evidence for screening and systemic management

Intervention	Verdict	Notes
Annual or 1–2-yearly retinal screening	🟢 Strong	Endorsed by NHMRC, RANZCO, ADS, RACGP; reduces blindness; cost-effective
Non-mydriatic retinal photography in general practice (MBS 12325)	🟢 Strong	High sensitivity for sight-threatening DR; addresses access barriers; requires training and quality assurance
Intensive glycaemic control (HbA1c ~7%)	🟢 Strong	DCCT — 76% reduction (T1DM); UKPDS — 25% reduction in microvascular endpoints (T2DM); individualise target
Rapid HbA1c reduction risk — early worsening	🟢 Strong	Well-described; co-manage with ophthalmology when rapid intensification is planned
Blood pressure control < 130/80 mmHg	🟢 Strong	UKPDS 38 — tight BP control reduced microvascular endpoints; meta-analyses confirm
Fenofibrate in T2DM with DR	🟢 Reasonable	FIELD (Keech 2007) and ACCORD-Eye (Chew 2010) — ~30% reduction in need for laser; effect independent of lipid changes
Smoking cessation	🟢 Strong	Reduces all vascular complications; multifactorial benefit
Anti-VEGF for DMO (ranibizumab, aflibercept, faricimab)	🟢 Strong	RIDE/RISE, VIVID/VISTA, DRCR Protocol T, YOSEMITE/RHINE RCTs — superior to laser for centre-involving DMO
Panretinal photocoagulation (PRP) for PDR	🟢 Established	DRS landmark trial — reduced severe vision loss by ~50%; durable single-treatment option; still preferred in compliance-limited patients
Aspirin for DR prevention (without CV indication)	🔴 No benefit	ETDRS — aspirin neither increased nor decreased vitreous haemorrhage; use only for cardiovascular indications
Antioxidant / vitamin supplementation for DR prevention	🟡 No clear evidence	AREDS-style supplementation is for AMD, not DR; routine supplementation not endorsed

C. Specialist management — what happens after referral

Specialist-led treatment for diabetic retinopathy includes anti-VEGF injections, laser, and surgery.

Anti-VEGF intravitreal injections are the mainstay of treatment for diabetic macular oedema and, in selected patients, proliferative DR. These medications block vascular endothelial growth factor (VEGF), reducing abnormal vascular permeability and neovascularisation. PBS-listed agents (Authority Required criteria apply):

• Ranibizumab (Lucentis) — for DMO and DR meeting specific PBS criteria
• Aflibercept (Eylea, Eylea HD) — for DMO and DR
• Faricimab (Vabysmo) — for DMO; the most recently listed agent; similar efficacy with potential for longer dosing intervals
• Bevacizumab (Avastin) — used off-label as a compounded preparation in some public services

A typical loading course of three to five monthly injections is followed by extended-interval “treat-and-extend” dosing. Long-term treatment — often years — is frequently required for DMO. The treating ophthalmologist manages the injection schedule.

Laser treatment:
Panretinal photocoagulation (PRP) destroys peripheral ischaemic retina to reduce VEGF production, and remains the first-line treatment for PDR in patients where ongoing anti-VEGF compliance cannot be assured, or where anti-VEGF is not appropriate. Focal or grid laser has a role in non-centre-involving DMO. Subthreshold micropulse laser is an emerging technique with reduced tissue destruction.

Intravitreal steroids:
Dexamethasone implant (Ozurdex) — PBS Authority for refractory DMO. Fluocinolone acetonide implant (Iluvien) — PBS Authority for chronic refractory DMO.

Vitreoretinal surgery (vitrectomy):
Indicated for non-clearing vitreous haemorrhage, tractional retinal detachment involving the macula, or severe vitreomacular traction contributing to DMO.

The ETDRS and DRCR.net clinical protocols are the evidence foundation for modern DR management. Decisions about the choice and timing of treatment are made by the treating retinal specialist.

D. Australian operations

MBS items for diabetic retinopathy in general practice:

• Item 12325 — non-mydriatic retinal photography by an accredited GP, registered nurse, or appropriately trained practitioner; rebatable every 24 months for people with diabetes (or as indicated). Requires practitioner accreditation, training, and image quality assurance
• Standard consultation items (23, 36, 44; telehealth equivalents)
• GPMP (721) and TCA (723) — coordinate optometry, podiatry, dietitian, exercise physiology; directly relevant to the diabetes cycle of care
• MBS 715 — Aboriginal and Torres Strait Islander health assessment, which includes an eye screening component
• Health assessments (701/703/705/707) for older patients
• Visiting Optometrists Scheme — federally funded outreach to remote and very remote communities

KeepSight registry:
KeepSight, administered by Diabetes Australia, is a free national recall and reminder system for diabetes eye screening. The GP, optometrist, or ophthalmologist can register a patient with their consent. KeepSight sends annual reminders directly to patients and supports population-level screening adherence tracking. Registration takes minutes and is strongly recommended for all people with diabetes.

NDSS and support:
The National Diabetes Services Scheme (NDSS) provides access to subsidised products, information, and education programs. NDSS-funded diabetes educators, dietitians, and podiatrists can be referred under the GPMP/TCA framework.

PBS medicines relevant to diabetic retinopathy management:

• Anti-VEGF agents (ranibizumab, aflibercept, faricimab, dexamethasone implant, fluocinolone implant) — PBS Authority Required (specialist prescriber)
• Fenofibrate — PBS for hypertriglyceridaemia; consider in T2DM with established DR and elevated triglycerides
• Antidiabetic agents: metformin (general), SGLT2 inhibitors (Authority — eGFR/cardiovascular criteria), GLP-1 receptor agonists (Authority — combination criteria), DPP-4 inhibitors (Authority), insulin (general or Authority by formulation)
• Antihypertensives: ACEi, ARB, CCB, diuretics — PBS general
• Smoking cessation agents: varenicline, bupropion (Authority), nicotine replacement therapy

E. Special populations

Type 1 diabetes:
The DCCT and its long-term follow-up study (EDIC) confirmed that intensive glycaemic control during the early years of type 1 diabetes produces a lasting “metabolic memory” effect that reduces microvascular complications for decades. Regular ophthalmology review is particularly important in young people with type 1 diabetes, and paediatric ophthalmology services are available for children.

Pregnancy with pre-existing diabetes:
DR can progress rapidly during pregnancy, including paradoxical worsening at the start of intensive glucose management. The RACGP and RANZCO recommend ophthalmology review before conception, at each trimester, and six to twelve weeks postpartum. Statins must be ceased before conception (teratogenic). ACE inhibitors and ARBs are contraindicated in pregnancy and should be switched to an alternative antihypertensive (e.g., labetalol, nifedipine, methyldopa) pre-conception or as soon as pregnancy is confirmed.

Aboriginal and Torres Strait Islander patients:
Aboriginal and Torres Strait Islander Australians have approximately three times the rate of vision impairment from diabetic retinopathy compared with non-Indigenous Australians — a disparity that reflects access barriers to both diabetes management and eye screening. The Roadmap to Close the Gap for Vision (Indigenous Eye Health, University of Melbourne) guides national strategy. MBS 715 annual health assessments include eye screening. Outreach ophthalmology services, the Visiting Optometrists Scheme, and AI-assisted retinal screening programs are improving access in remote and very remote communities. Engage Aboriginal Health Workers and community health workers to support screening uptake and adherence.

Older adults:
Older people with long-standing type 2 diabetes are at elevated risk of advanced retinopathy and cataract. Functional vision loss in older adults has particular consequences for independence, falls risk, and driving fitness. A driving fitness assessment per Austroads standards is required if vision is impaired. Low-vision rehabilitation (Vision Australia, Guide Dogs Australia) supports independence after vision loss.

When to escalate

Refer to or contact ophthalmology urgently when:

• Sudden change in vision, new floaters, or a curtain across the visual field in a person with diabetes — same-day review to exclude vitreous haemorrhage or retinal detachment
• Retinal photography reveals moderate or severe NPDR — ophthalmology referral within 2–3 months
• Proliferative DR detected on retinal photography — ophthalmology within weeks
• Grade IV hypertensive retinopathy (papilloedema) — this is a hypertensive emergency; immediate blood pressure management and urgent ophthalmology review
• Pupil-involving third nerve palsy — urgent MRI to exclude posterior communicating artery aneurysm
• Planned rapid HbA1c intensification in a patient with known DR — coordinate with ophthalmology before intensifying glycaemia to monitor for early worsening

What this article is and is not

This is general health information based on Australian clinical guidelines — RACGP Management of Type 2 Diabetes, NHMRC Diabetic Retinopathy Guidelines, RANZCO guidance, and eTG — and landmark trials including DCCT, UKPDS, FIELD, ACCORD-Eye, and ETDRS. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about screening intervals, referral timing, and treatment options require assessment by your own GP and treating ophthalmologist.

For Australian diabetes support: Diabetes Australia, NDSS, KeepSight, Vision Australia.

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Sources cited

1. RACGP — Management of type 2 diabetes: a handbook for general practice
2. eTG complete — Endocrinology / Eye
3. NHMRC — Guidelines for the Management of Diabetic Retinopathy
4. RANZCO — Diabetic Retinopathy Guidelines
5. Diabetes Australia — KeepSight registry
6. Australian Diabetes Society — Position statements
7. NDSS — National Diabetes Services Scheme
8. MBS Online — Item 12325 retinal photography
9. PBS — Anti-VEGF and other Authority listings
10. Vision 2020 Australia — Eye health roadmap
11. Optometry Australia — Diabetes and the eye
12. Indigenous Eye Health — Roadmap to Close the Gap for Vision
13. ETDRS — Early Treatment Diabetic Retinopathy Study
14. UKPDS 33 — Intensive blood-glucose control in type 2 diabetes (Lancet 1998)