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ophtho.diabetic-retinopathy.core.v1PRODUCTION
ophtho.diabetic-retinopathy.core.v1

Diabetic retinopathy and diabetic macular edema

general_internal_medicinechronicsubacuteadultpediatricpregnancygeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Frame as a microvascular complication of diabetes producing capillary dropout, microaneurysms, IRMA, macular oedema, and (proliferative) neovascularisation with risk of vitreous haemorrhage and tractional detachment. Engine drives ETDRS / ICDR staging, OCT-based DME assessment, and a tiered anti-VEGF / PRP / steroid / vitrectomy ladder. Early-worsening with rapid glycemic correction or pregnancy is the over-arching guardrail (ADA Standards 2026; AAO PPP DR 2025).

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DR framing + early-worsening guardrail set

Patient inputs (11)

HbA1c and trend gates the early-worsening risk; rapid drop >2 percentage points / 6 months merits earlier follow-up (ADA Standards 2026)

Hypertension and dyslipidaemia accelerate DR; BP <130/80 and statin therapy are part of the disease-modifying treatment (ADA Standards 2026; ACCORD-Eye fenofibrate signal)

Pregnancy itself can accelerate DR; treat pre-existing severe NPDR / PDR before conception where possible; screen first trimester then q1-3 months (ADA Standards 2026)

Rapid glycemic intensification (new GLP-1 / SGLT2 / insulin start, bariatric surgery) can precipitate early DR worsening — schedule follow-up sooner (ADA Standards 2026)

Type (T1/T2), duration, and most recent HbA1c set the pretest map and screening cadence (ADA Standards 2026; UKPDS)

Dilated fundus (or ultra-widefield) examination is the diagnostic substrate — stage by ETDRS / ICDR scale (no DR / mild / moderate / severe NPDR / PDR) (AAO PPP DR 2025)

SD-OCT identifies and quantifies macular oedema (centre-involving vs non-centre-involving); central subfield thickness is the primary anti-VEGF treatment trigger and monitoring metric (AAO PPP DR 2025)

FA / OCT-A maps ischaemia and neovascularisation (NVD/NVE), informs PRP vs anti-VEGF decision in PDR (AAO PPP DR 2025; Protocol S)

Diabetic nephropathy commonly co-progresses with DR; eGFR also gates renally-cleared concurrent therapies (CKD-EPI 2021)

Cataract risk from intravitreal corticosteroid implants is major in phakic eyes; pseudophakic patients are reasonable steroid-implant candidates (AAO PPP DR 2025)

Baseline IOP gates intravitreal corticosteroid implant decisions; steroid-responder OAG complicates triamcinolone / dex / fluocinolone implants (AAO PPP DR 2025)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningpdr_with_vitreous_hemorrhage_or_tractional_rd
    PDR with sudden visual loss + dense floaters / curtain — vitreous haemorrhage or tractional retinal detachment
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_injection_endophthalmitis
    Pain + redness + hypopyon after intravitreal injection
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereearly_worsening_rapid_glycemic_correction
    HbA1c drop >2 percentage points within 6 months or new SGLT2/GLP1/intensive-insulin start with pre-existing severe NPDR / PDR
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_or_pre_conception_with_dr
    Pregnant patient or pre-conception planning with any DR — pregnancy itself accelerates DR
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_npdr_high_progression_risk
    Severe NPDR by ICDR (4-2-1 rule) — ~50% 1-year PDR conversion risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecentre_involving_dme_with_vision_loss
    OCT centre-involving DME with vision impairment
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesteroid_implant_iop_rise
    IOP elevation after intravitreal dexamethasone / fluocinolone implant
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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CONTEXToptionalDrives risk stratification
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Recommended regimen

DR + DME — systemic optimisation, stage-appropriate intravitreal therapy, PRP / vitrectomy (AAO PPP DR 2025; Protocol S; YOSEMITE/RHINE)
axis: dr_dme_stepwise_treatment_ladderstep 1 - Step 1 — Systemic optimisation (every patient, every stage)
Selected step "Step 1 — Systemic optimisation (every patient, every stage)" — All patients with DR or at risk; the disease-modifying foundation beneath every ocular tier
  • glycemic_bp_lipid_optimisation
    first line
    systemic_disease_modifier
    triggers: any_dr_stage, pre_dr_diabetes
    ADA Standards 2026 + UKPDS: HbA1c to individualised target, BP <130/80, statin therapy. Avoid abrupt large HbA1c drops in severe DR (early-worsening risk). ACCORD-Eye signal supports fenofibrate adjunct.
  • pregnancy_co_management_with_mfm
    first line
    pathway_decision
    triggers: pregnancy_or_pre_conception, severe_npdr_or_pdr_in_pregnancy
    ADA Standards 2026 — pregnancy accelerates DR; pre-conception treatment of severe NPDR/PDR where possible; first-trimester screen then q1-3 months.

outpatient playbook — drug actions (5)

  1. 1. systemic optimisation — HbA1c, BP, lipid; pregnancy co-management
    individualised • systemic • lifelong
    trigger: Any DR stage (ADA Standards 2026)
    Disease-modifying foundation; avoid abrupt large HbA1c drop in severe DR; treat severe NPDR / PDR pre-conception where possible
  2. 2. faricimab intravitreal (centre-involving DME, durability preferred)
    rxcui 2591519
    6 mg / 0.05 mL • intravitreal • q4 wk x4 then q8 wk or T&E q4-16 wk
    trigger: Centre-involving DME with vision loss (YOSEMITE/RHINE PMID 35085503)
    Non-inferior to aflibercept; many patients extended to q12-16 wk
  3. 3. aflibercept 2 mg (Protocol T first choice for baseline VA <=20/50)
    rxcui 1232150
    2 mg / 0.05 mL • intravitreal • q4 wk x5 then q8 wk
    trigger: Centre-involving DME (Protocol T)
    Superior to bevacizumab/ranibizumab in worse-vision subgroup
  4. 4. ranibizumab (PDR — Protocol S)
    rxcui 595060
    0.5 mg • intravitreal • baseline + per Protocol S re-treatment
    trigger: PDR — Gross JAMA 2015 PMID 26565927
    Non-inferior to PRP at 2 y with less peripheral VF loss; counsel visit burden
  5. 5. bevacizumab off-label (cost-constrained centre-involving DME)
    rxcui 253337
    1.25 mg / 0.05 mL • intravitreal • q4 wk then extended
    trigger: Access barrier (Protocol T)
    Equivalent at baseline VA >=20/40

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Diabetes mellitus due for screening — T1DM >=5 y from diagnosis or at puberty; T2DM at diagnosis; q1-2 y thereafter; pregnancy pre-conception or first trimester (ADA Standards 2026; AAO PPP DR 2025); Painless blurred / distorted central vision in a patient with diabetes — diabetic macular oedema (DME) is the dominant cause of vision loss in DR (AAO PPP DR 2025); Sudden vision loss, dense floaters, or visual curtain in a known diabetic — pre-retinal / vitreous haemorrhage or tractional retinal detachment from PDR (AAO PPP DR 2025).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Diabetic retinopathy and diabetic macular edema** (ophtho.diabetic-retinopathy.core.v1).
Phenotype framing: Terminal differential: diabetic retinopathy (microaneurysms, dot/blot haemorrhages, exudates, NV in a diabetic) vs retinal vein occlusion (sectoral haemorrhage + cotton-wool spots in the venous territory) vs hypertensive retinopathy (arteriolar narrowing, AV nicking, no microaneurysms early) vs radiation retinopathy (history) vs OIS (carotid stenosis with mid-peripheral haemorrhages and pain) vs sickle retinopathy (sea-fan NV) (AAO PPP DR 2025).
Scope: Frame as a microvascular complication of diabetes producing capillary dropout, microaneurysms, IRMA, macular oedema, and (proliferative) neovascularisation with risk of vitreous haemorrhage and tractional detachment. Engine drives ETDRS / ICDR staging, OCT-based DME assessment, and a tiered anti-VEGF / PRP / steroid / vitrectomy ladder. Early-worsening with rapid glycemic correction or pregnancy is the over-arching guardrail (ADA Standards 2026; AAO PPP DR 2025).

No severity triggers fired against current inputs.

Plan

Regimen axis: **DR + DME — systemic optimisation, stage-appropriate intravitreal therapy, PRP / vitrectomy (AAO PPP DR 2025; Protocol S; YOSEMITE/RHINE)** — step "Step 1 — Systemic optimisation (every patient, every stage)".
1. glycemic_bp_lipid_optimisation (systemic_disease_modifier, first line) — ADA Standards 2026 + UKPDS: HbA1c to individualised target, BP <130/80, statin therapy. Avoid abrupt large HbA1c drops in severe DR (early-worsening risk). ACCORD-Eye signal supports fenofibrate adjunct.
2. pregnancy_co_management_with_mfm (pathway_decision, first line) — ADA Standards 2026 — pregnancy accelerates DR; pre-conception treatment of severe NPDR/PDR where possible; first-trimester screen then q1-3 months.

Setting playbook (outpatient) — Screen at the ADA cadence, stage by ICDR, quantify DME on OCT, optimise systemic risk factors, and deliver stage-appropriate anti-VEGF / PRP / steroid / vitrectomy with guardrails for rapid glycemic correction and pregnancy (ADA Standards 2026; AAO PPP DR 2025; Protocol S PMID 26565927; YOSEMITE/RHINE PMID 35085503)
3. systemic optimisation — HbA1c, BP, lipid; pregnancy co-management individualised systemic lifelong — Any DR stage (ADA Standards 2026) (Disease-modifying foundation; avoid abrupt large HbA1c drop in severe DR; treat severe NPDR / PDR pre-conception where possible)
4. faricimab intravitreal (centre-involving DME, durability preferred) 6 mg / 0.05 mL intravitreal q4 wk x4 then q8 wk or T&E q4-16 wk — Centre-involving DME with vision loss (YOSEMITE/RHINE PMID 35085503) (Non-inferior to aflibercept; many patients extended to q12-16 wk)
5. aflibercept 2 mg (Protocol T first choice for baseline VA <=20/50) 2 mg / 0.05 mL intravitreal q4 wk x5 then q8 wk — Centre-involving DME (Protocol T) (Superior to bevacizumab/ranibizumab in worse-vision subgroup)
6. ranibizumab (PDR — Protocol S) 0.5 mg intravitreal baseline + per Protocol S re-treatment — PDR — Gross JAMA 2015 PMID 26565927 (Non-inferior to PRP at 2 y with less peripheral VF loss; counsel visit burden)
7. bevacizumab off-label (cost-constrained centre-involving DME) 1.25 mg / 0.05 mL intravitreal q4 wk then extended — Access barrier (Protocol T) (Equivalent at baseline VA >=20/40)

Non-pharmacologic actions:
- Panretinal photocoagulation for high-risk PDR especially where anti-VEGF visit adherence is uncertain (DRS / ETDRS)
- Intravitreal dexamethasone (Ozurdex) implant for pseudophakic or anti-VEGF-incomplete-response DME (AAO PPP DR 2025)
- Intravitreal fluocinolone (Iluvien) implant for chronic pseudophakic DME (long-acting; IOP risk)
- Vitrectomy for non-clearing vitreous haemorrhage or tractional retinal detachment
- Cataract surgery planning includes peri-operative anti-VEGF or steroid if active DME, to prevent post-op worsening

AVOID / contraindication checks:
- Avoid rapid large HbA1c drops in severe DR pre existing (early worsening risk; ADA Standards 2026)
- Treat severe NPDR or PDR before pregnancy where feasible (ADA Standards 2026)
- Intravitreal corticosteroid implants cause cataract in phakic eyes and IOP rise (AAO PPP DR 2025)
- Post intravitreal injection endophthalmitis routes OUT to ophtho.endophthalmitis.core.v1
- Brolucizumab intraocular inflammation and retinal vasculitis signal — reserve for selected cases (KESTREL/KITE; FDA letter)

Monitoring

Regimen monitoring:
- OCT central subfield thickness and visual acuity at each anti VEGF visit (AAO PPP DR 2025)
- ICDR stage and NV extent at each examination (AAO PPP DR 2025)
- IOP at 2 6 weeks and 3 monthly after steroid implant (AAO PPP DR 2025)
- HbA1c BP lipids per ADA cadence (ADA Standards 2026)
- Pregnancy screen first trimester then q1 3 months (ADA Standards 2026)

Setting (outpatient) monitoring:
- OCT + VA at each anti-VEGF visit; ICDR re-grade at every visit; IOP after steroid implant (AAO PPP DR 2025)
- HbA1c, BP, lipids per ADA cadence (ADA Standards 2026)
- Pregnancy q1-3 months ophthalmology + maternal-fetal medicine (ADA Standards 2026)

Follow-up plan: Lifelong screening + treatment arc. Adjust cadence by ICDR stage: q12-24 mo no DR, q12 mo mild, q6-12 mo moderate/severe NPDR, q1-4 mo PDR / DME on therapy. Pregnancy: pre-conception baseline then q1-3 months. Co-manage cataract surgery (DME can worsen post-op — peri-operative anti-VEGF or steroid). Low-vision rehabilitation for irreversible field loss / advanced disease (AAO PPP DR 2025; ADA Standards 2026).
- Close-out criterion: stage-appropriate cadence + cataract / pregnancy / low-vision planning documented

Monitoring phase: OCT central subfield thickness and visual acuity at each anti-VEGF visit; ICDR stage and presence/extent of NV at each examination. After PRP: monitor regression of NV at 4-6 weeks then 3-monthly. After steroid implant: IOP at 2-6 weeks and 3-monthly (steroid-responder IOP rise / open-angle glaucoma risk). HbA1c, BP, lipids per ADA cadence.

Disposition

Current setting: outpatient — Screen at the ADA cadence, stage by ICDR, quantify DME on OCT, optimise systemic risk factors, and deliver stage-appropriate anti-VEGF / PRP / steroid / vitrectomy with guardrails for rapid glycemic correction and pregnancy (ADA Standards 2026; AAO PPP DR 2025; Protocol S PMID 26565927; YOSEMITE/RHINE PMID 35085503)

Disposition criteria:
- Continue outpatient retina co-management with stage-appropriate cadence (AAO PPP DR 2025)
- Vitreoretinal-surgery referral for advanced PDR complications
- Endocrinology / maternal-fetal-medicine co-management for HbA1c, BP, lipids, pregnancy (ADA Standards 2026)

Escalation triggers (move to higher acuity):
- PDR with vitreous haemorrhage / tractional RD → same-day vitreoretinal referral
- Pain + redness + hypopyon after intravitreal injection → ophtho.endophthalmitis.core.v1
- Rapid HbA1c drop >2 percentage points / 6 months with severe NPDR or pregnancy → tighter follow-up cadence

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] PDR with sudden visual loss + dense floaters / curtain — vitreous haemorrhage or tractional retinal detachment
- [LIFE_THREATENING] Pain + redness + hypopyon after intravitreal injection
- [SEVERE] HbA1c drop >2 percentage points within 6 months or new SGLT2/GLP1/intensive-insulin start with pre-existing severe NPDR / PDR

Citations

- ADA Standards of Care in Diabetes 2026 (retinopathy screening cadence) + AAO Preferred Practice Pattern Diabetic Retinopathy 2025 cycle + Protocol S (Gross et al, JAMA 2015, PMID 26565927 — ranibizumab vs PRP for PDR) + YOSEMITE & RHINE (Wykoff et al, Lancet 2022, PMID 35085503 — faricimab DME with up-to-q16wk durability) [PMID:26565927](https://pubmed.ncbi.nlm.nih.gov/26565927/)
- Cited evidence (PMID 35085503) [PMID:35085503](https://pubmed.ncbi.nlm.nih.gov/35085503/)

Last reconciled with current guidelines: 2026-05-26.
References
  • ADA Standards of Care in Diabetes 2026 (retinopathy screening cadence) + AAO Preferred Practice Pattern Diabetic Retinopathy 2025 cycle + Protocol S (Gross et al, JAMA 2015, PMID 26565927 — ranibizumab vs PRP for PDR) + YOSEMITE & RHINE (Wykoff et al, Lancet 2022, PMID 35085503 — faricimab DME with up-to-q16wk durability) — PMID:26565927
  • Cited evidence (PMID 35085503) — PMID:35085503