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DOI: 10.1055/s-0045-1814081
Consensus Guidelines for the Screening and Management of Diabetic Retinopathy in the Gulf Region
Authors
Abstract
Diabetic Retinopathy (DR) is the world's leading cause of preventable blindness among working age adults, and affects individuals with diabetes mellitus (DM), including type 1 and type 2 DM, among others. The global increase in the prevalence of DM has been accompanied by a parallel increase in the prevalence (20–40%) of DR, especially in countries like Saudi Arabia, United Arab Emirates, Kuwait, Qatar, Bahrain, and Oman. Research on DR in the Gulf region is limited; however, several common risk factors drive the development and progression of DR, including poor glycemic control, hypertension, and hyperlipidemia. There is also a need for effective screening and management programs for DR. The development of tailored region-specific guidelines for the Gulf region is key to effective DR prevention, early detection, and treatment. The current health care systems and information technology infrastructure are sufficiently well-developed to implement national DR screening programs and cohesive management strategies through primary and secondary care to have a major impact on reducing blindness in the Gulf region.
Keywords
anti-VEGF - diabetes mellitus - diabetic macular edema - diabetic retinopathy - ophthalmic screening - type 1 diabetes - type 2 diabetesAuthor Contributions
All authors contributed to the writing and review of the manuscript. F.A. is the principal editor and first author for the manuscript.
Data Availability Statement
All data generated during this initiative are included in this article. Further inquiries can be directed to the corresponding author.
Publication History
Article published online:
02 December 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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References
- 1 Wong TY, Tan TE. the diabetic retinopathy “pandemic” and evolving global strategies: the 2023 Friedenwald Lecture. Invest Ophthalmol Vis Sci 2023; 64 (15) 47-47
- 2 Al-Ghamdi AS. Adults visual impairment and blindness - an overview of prevalence and causes in Saudi Arabia. Saudi J Ophthalmol 2019; 33 (04) 374-381
- 3 Al-Maskari F, El-Sadig M. Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey. BMC Ophthalmol 2007; 7 (01) 11
- 4 Al-Sarraf A, Al-Bannai S, Al-Furaih S, El-Shazly M. (2010). Prevalence and factors associated with diabetic retinopathy, a multi-centric study in Kuwait. Alexandria Journal of Medicine, [online] 46(2), pp.99–108. Accessed February 26, 2020 at: https://www.ajol.info/index.php/bafm/article/view/61004
- 5 Elshafei M, Gamra H, Khandekar R, Al Hashimi M, Pai A, Ahmed MF. Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: a community-based survey. Eur J Ophthalmol 2011; 21 (01) 39-47
- 6 Al Alawi E, Ahmed AA. Screening for diabetic retinopathy: the first telemedicine approach in a primary care setting in Bahrain. Middle East Afr J Ophthalmol 2012; 19 (03) 295-298
- 7 Agroiya P, Alrawahi AH, Pambinezhuth F, Al Busaidi NB. Diabetic retinopathy among Omanis: prevalence and clinical profile. Oman J Ophthalmol 2020; 13 (02) 76-83
- 8 Deshpande AD, Harris-Hayes M, Schootman M. Epidemiology of diabetes and diabetes-related complications. Phys Ther 2008; 88 (11) 1254-1264
- 9 Romero-Aroca P, Navarro-Gil R, Valls-Mateu A, Sagarra-Alamo R, Moreno-Ribas A, Soler N. Differences in incidence of diabetic retinopathy between type 1 and 2 diabetes mellitus: a nine-year follow-up study. Br J Ophthalmol 2017; 101 (10) 1346-1351
- 10 Hong J, Surapaneni A, Daya N. et al. Retinopathy and risk of kidney disease in persons with diabetes. Kidney Med 2021; 3 (05) 808-815.e1
- 11 Hsu CY, Lee CM, Chou KY. et al. The association of diabetic retinopathy and cardiovascular disease: a 13-year nationwide population-based cohort study. Int J Environ Res Public Health 2021; 18 (15) 8106
- 12 Al-Faris EA. Guidelines for the management of diabetic patients in the health centers of Saudi Arabia. J Family Community Med 1997; 4 (01) 12-23
- 13 Alawadi F, Abusnana S, Afandi B. et al. Emirates Diabetes Society Consensus guidelines for the management of type 2 diabetes mellitus – 2020. Dubai Diabetes Endocrinol J 2020; 26 (01) 1-20
- 14 Wong TY, Cheung N, Tay WT. et al. Prevalence and risk factors for diabetic retinopathy: the Singapore Malay Eye Study. Ophthalmology 2008; 115 (11) 1869-1875
- 15 De Block CEM, De Leeuw IH, Van Gaal LF. Impact of overweight on chronic microvascular complications in type 1 diabetic patients. Diabetes Care 2005; 28 (07) 1649-1655
- 16 Gadkari SS, Maskati QB, Nayak BK. Prevalence of diabetic retinopathy in India: the All India Ophthalmological Society Diabetic Retinopathy Eye Screening Study 2014. Indian J Ophthalmol 2016; 64 (01) 38-44
- 17 Shah K, Gandhi A, Natarajan S. Diabetic retinopathy awareness and associations with multiple comorbidities: insights from DIAMOND Study. Indian J Endocrinol Metab 2018; 22 (01) 30-35
- 18 Bertelsen G, Peto T, Lindekleiv H. et al. Sex differences in risk factors for retinopathy in non-diabetic men and women: the Tromsø Eye Study. Acta Ophthalmol 2014; 92 (04) 316-322
- 19 Stratton IM, Kohner EM, Aldington SJ. et al. UKPDS 50: risk factors for incidence and progression of retinopathy in Type II diabetes over 6 years from diagnosis. Diabetologia 2001; 44 (02) 156-163
- 20 Olsen BS, Sjølie A, Hougaard P. et al; Danish Study Group of Diabetes in Childhood. A 6-year nationwide cohort study of glycaemic control in young people with type 1 diabetes. Risk markers for the development of retinopathy, nephropathy and neuropathy. J Diabetes Complications 2000; 14 (06) 295-300
- 21 Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: a systematic review. JAMA 2007; 298 (08) 902-916
- 22 Singh C, Prasad SP, Kaul S, Motwani D, Mishra A, Padmakumar V. Association of HbA1c levels with diabetic retinopathy. Indian J Clin Experiment Ophthalmol 2021; 7 (02) 339-345
- 23 Diabetes Control and Complications Trial Research Group. Progression of retinopathy with intensive versus conventional treatment in the Diabetes Control and Complications Trial. Ophthalmology 1995; 102 (04) 647-661
- 24 The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes 1995; 44 (08) 968-983
- 25 UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352 (9131): 837-853
- 26 Tan MP, Alwi SS, Intan G. Diabetic retinopathy and the effect of pregnancy. Malaysian Family Phys 2010; 5 (01) 2-5
- 27 Liu L, Quang ND, Banu R. et al. Hypertension, blood pressure control and diabetic retinopathy in a large population-based study. PLoS One 2020; 15 (03) e0229665
- 28 Diabetes Control and Complications Trial Research Group. Effect of pregnancy on microvascular complications in the Diabetes Control and Complications Trial. Diabetes Care 2000; 23 (08) 1084-1091
- 29 Suzuma I, Hata Y, Clermont A. et al. Cyclic stretch and hypertension induce retinal expression of vascular endothelial growth factor and vascular endothelial growth factor receptor-2: potential mechanisms for exacerbation of diabetic retinopathy by hypertension. Diabetes 2001; 50 (02) 444-454
- 30 Rajalakshmi R, Prathiba V, Mohan V. Does tight control of systemic factors help in the management of diabetic retinopathy?. Indian J Ophthalmol 2016; 64 (01) 62-68
- 31 UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317 (7160): 703-713
- 32 Klein R, Klein BE. Blood pressure control and diabetic retinopathy. Br J Ophthalmol 2002; 86 (04) 365-367
- 33 Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002; 61 (03) 1086-1097
- 34 Adler AI, Stratton IM, Neil HA. et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000; 321 (7258): 412-419
- 35 Ciulla TA, Amador AG, Zinman B. Diabetic retinopathy and diabetic macular edema: pathophysiology, screening, and novel therapies. Diabetes Care 2003; 26 (09) 2653-2664
- 36 Chang YC, Wu WC. Dyslipidemia and diabetic retinopathy. Rev Diabet Stud 2013; 10 (2–3): 121-132
- 37 Atchison E, Barkmeier A. The role of systemic risk factors in diabetic retinopathy. Curr Ophthalmol Rep 2016; 4 (02) 84-89
- 38 Klein BEK, Moss SE, Klein R, Surawicz TS. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. XIII. Relationship of serum cholesterol to retinopathy and hard exudate. Ophthalmology 1991; 98 (08) 1261-1265
- 39 Chew EY, Klein ML, Ferris III FL. et al. Association of elevated serum lipid levels with retinal hard exudate in diabetic retinopathy. Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch Ophthalmol 1996; 114 (09) 1079-1084
- 40 Rema M, Srivastava BK, Anitha B, Deepa R, Mohan V. Association of serum lipids with diabetic retinopathy in urban South Indians–the Chennai Urban Rural Epidemiology Study (CURES) Eye Study–2. Diabet Med 2006; 23 (09) 1029-1036
- 41 Comer GM, Ciulla TA. Pharmacotherapy for diabetic retinopathy. Curr Opin Ophthalmol 2004; 15 (06) 508-518
- 42 Gaedt Thorlund M, Borg Madsen M, Green A, Sjølie AK, Grauslund J. Is smoking a risk factor for proliferative diabetic retinopathy in type 1 diabetes?. Ophthalmologica 2013; 230 (01) 50-54
- 43 Campagna D, Alamo A, Di Pino A. et al. Smoking and diabetes: dangerous liaisons and confusing relationships. Diabetol Metab Syndr 2019; 11 (01) 85
- 44 Pradeepa R, Surendar J, Indulekha K, Chella S, Anjana RM, Mohan V. Relationship of diabetic retinopathy with coronary artery disease in Asian Indians with type 2 diabetes: the Chennai Urban Rural Epidemiology Study (CURES) Eye Study–3. Diabetes Technol Ther 2015; 17 (02) 112-118
- 45 He BB, Xu M, Wei L. et al. Relationship between anemia and chronic complications in Chinese patients with type 2 diabetes mellitus. Arch Iran Med 2015; 18 (05) 277-283
- 46 McGill JB, Bell DSH. Anemia and the role of erythropoietin in diabetes. J Diabetes Complications 2006; 20 (04) 262-272
- 47 Pradeepa R, Anjana RM, Unnikrishnan R, Ganesan A, Mohan V, Rema M. Risk factors for microvascular complications of diabetes among South Indian subjects with type 2 diabetes–the Chennai Urban Rural Epidemiology Study (CURES) Eye Study-5. Diabetes Technol Ther 2010; 12 (10) 755-761
- 48 Rani PK, Raman R, Gupta A, Pal SS, Kulothungan V, Sharma T. Albuminuria and diabetic retinopathy in type 2 diabetes mellitus Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS, report 12). Diabetol Metab Syndr 2011; 3 (01) 9
- 49 Graue-Hernandez EO, Rivera-De-La-Parra D, Hernandez-Jimenez S, Aguilar-Salinas CA, Kershenobich-Stalnikowitz D, Jimenez-Corona A. Prevalence and associated risk factors of diabetic retinopathy and macular oedema in patients recently diagnosed with type 2 diabetes. BMJ Open Ophthalmol 2020; 5 (01) e000304
- 50 American Academy of Ophthalmology. Diabetic retinopathy: screening, treatment, and trends. 2024 [online]. Accessed November 18, 2025 at: https://www.aao.org/eyenet/article/diabetic-retinopathy-screening-treatment-trends
- 51 Diabetes.ca. 2018. My Site - Chapter 34: Type 1 Diabetes in Children and Adolescents. [online]. Accessed November 18, 2025 at: https://guidelines.diabetes.ca/cpg/chapter34
- 52 Javitt JC, Aiello LP. Cost-effectiveness of detecting and treating diabetic retinopathy. Ann Intern Med 1996; 124 (1, Pt 2): 164-169
- 53 NICE. Type 2 Diabetes in Adults: Management. London: National Institute for Health and Care Excellence; 2015
- 54 Lim JI, Regillo CD, Sadda SR. et al. Artificial Intelligence detection of diabetic retinopathy: subgroup comparison of the EyeArt system with ophthalmologists' dilated examinations. Ophthalmol Sci 2022; 3 (01) 100228
- 55 Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. IX. Four-year incidence and progression of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1989; 107 (02) 237-243
- 56 Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. X. Four-year incidence and progression of diabetic retinopathy when age at diagnosis is 30 years or more. Arch Ophthalmol 1989; 107 (02) 244-249
- 57 Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1984; 102 (04) 520-526
- 58 Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. Arch Ophthalmol 1984; 102 (04) 527-532
- 59 Klein R, Moss SE, Klein BE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. XI. The incidence of macular edema. Ophthalmology 1989; 96 (10) 1501-1510
- 60 Klein R, Klein BE, Moss SE, Cruickshanks KJ. The Wisconsin Epidemiologic Study of Diabetic Retinopathy: XVII. The 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology 1998; 105 (10) 1801-1815
- 61 Davis MD, Fisher MR, Gangnon RE. et al. Risk factors for high-risk proliferative diabetic retinopathy and severe visual loss: Early Treatment Diabetic Retinopathy Study Report #18. Invest Ophthalmol Vis Sci 1998; 39 (02) 233-252
- 62 Qiao Q, Keinänen-Kiukaanniemi S, Läärä E. The relationship between hemoglobin levels and diabetic retinopathy. J Clin Epidemiol 1997; 50 (02) 153-158
- 63 Nathan DM, Genuth S, Lachin J. et al; Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329 (14) 977-986
- 64 White NH, Sun W, Cleary PA. et al. Prolonged effect of intensive therapy on the risk of retinopathy complications in patients with type 1 diabetes mellitus: 10 years after the Diabetes Control and Complications Trial. Arch Ophthalmol 2008; 126 (12) 1707-1715
- 65 Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359 (15) 1577-1589
- 66 Chew EY, Ambrosius WT, Davis MD. et al; ACCORD Study Group, ACCORD Eye Study Group. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med 2010; 363 (03) 233-244
- 67 Chew EY, Davis MD, Danis RP. et al; Action to Control Cardiovascular Risk in Diabetes Eye Study Research Group. The effects of medical management on the progression of diabetic retinopathy in persons with type 2 diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye Study. Ophthalmology 2014; 121 (12) 2443-2451
- 68 Diabetes.ca. 2014. Diabetes Canada | Clinical Practice Guidelines. [online]. Accessed October 4, 2024 at: https://guidelines.diabetes.ca/cpg/chapter30#bib0205
- 69 Beulens JW, Patel A, Vingerling JR. et al; AdRem project team, ADVANCE management committee. Effects of blood pressure lowering and intensive glucose control on the incidence and progression of retinopathy in patients with type 2 diabetes mellitus: a randomised controlled trial. Diabetologia 2009; 52 (10) 2027-2036
- 70 Early worsening of diabetic retinopathy in the Diabetes Control and Complications Trial. Arch Ophthalmol 1998; 116 (07) 874-886
- 71 Leiter LA, Bain SC, Hramiak I. et al. Cardiovascular risk reduction with once-weekly semaglutide in subjects with type 2 diabetes: a post hoc analysis of gender, age, and baseline CV risk profile in the SUSTAIN 6 trial. Cardiovasc Diabetol 2019; 18 (01) 73
- 72 Barkmeier AJ, Herrin J, Swarna KS. et al. Comparative effectiveness of glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, dipeptidyl peptidase-4 inhibitors, and sulfonylureas for sight-threatening diabetic retinopathy. Ophthalmol Retina 2024; 8 (10) 943-952
- 73 Eleftheriadou A, Riley D, Zhao SS. et al. Risk of diabetic retinopathy and diabetic macular oedema with sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in type 2 diabetes: a real-world data study from a global federated database. Diabetologia 2024; 67 (07) 1271-1282
- 74 Oshitari T, Asaumi N, Watanabe M, Kumagai K, Mitamura Y. Severe macular edema induced by pioglitazone in a patient with diabetic retinopathy: a case study. Vasc Health Risk Manag 2008; 4 (05) 1137-1140
- 75 Mauer M, Zinman B, Gardiner R. et al. Renal and retinal effects of enalapril and losartan in type 1 diabetes. N Engl J Med 2009; 361 (01) 40-51
- 76 Wang B, Wang F, Zhang Y. et al. Effects of RAS inhibitors on diabetic retinopathy: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2015; 3 (04) 263-274
- 77 Lyons TJ, Jenkins AJ, Zheng D. et al. Diabetic retinopathy and serum lipoprotein subclasses in the DCCT/EDIC cohort. Invest Ophthalmol Vis Sci 2004; 45 (03) 910-918
- 78 Lopes-Virella MF, Baker NL, Hunt KJ, Lyons TJ, Jenkins AJ, Virella G. DCCT/EDIC Study Group. High concentrations of AGE-LDL and oxidized LDL in circulating immune complexes are associated with progression of retinopathy in type 1 diabetes. Diabetes Care 2012; 35 (06) 1333-1340
- 79 Kang EY, Chen TH, Garg SJ. et al. Association of statin therapy with prevention of vision-threatening diabetic retinopathy. JAMA Ophthalmol 2019; 137 (04) 363-371
- 80 Preiss D, Logue J, Sammons E. et al. Effect of fenofibrate on progression of diabetic retinopathy. NEJM Evid 2024; 3 (08) a2400179
- 81 Keech AC, Mitchell P, Summanen PA. et al; FIELD study investigators. Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Lancet 2007; 370 (9600): 1687-1697
- 82 Sun JK, Glassman AR, Beaulieu WT. et al; Diabetic Retinopathy Clinical Research Network. Rationale and application of the protocol S anti-vascular endothelial growth factor algorithm for proliferative diabetic retinopathy. Ophthalmology 2019; 126 (01) 87-95
- 83 Bergerhoff K, Clar C, Richter B. Aspirin in diabetic retinopathy. A systematic review. Endocrinol Metab Clin North Am 2002; 31 (03) 779-793
- 84 Aiello LP, Cahill MT, Wong JS. Systemic considerations in the management of diabetic retinopathy. Am J Ophthalmol 2001; 132 (05) 760-776
- 85 Genest J, Frohlich J, Fodor G, McPherson R. Working Group on Hypercholesterolemia and Other Dyslipidemias. Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update. CMAJ 2003; 169 (09) 921-924
- 86 Stewart MW, Browning DJ, Landers MB. Current management of diabetic tractional retinal detachments. Indian J Ophthalmol 2018; 66 (12) 1751-1762
- 87 Royle P, Mistry H, Auguste, P, et al. 2015. Background. [online] Nih.gov. Accessed November 18, 2025 at: https://www.ncbi.nlm.nih.gov/books/NBK305090/
- 88 The Diabetic Retinopathy Study Research Group. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. Ophthalmology 1981; 88 (07) 583-600
- 89 Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology 1991; 98 (5, Suppl): 766-785
- 90 Muqit MMK, Marcellino GR, Henson DB. et al. Single-session vs multiple-session pattern scanning laser panretinal photocoagulation in proliferative diabetic retinopathy: The Manchester Pascal Study. Arch Ophthalmol 2010; 128 (05) 525-533
- 91 Sivaprasad S, Hykin P, Prevost AT. et al. Intravitreal Aflibercept Compared with Panretinal Photocoagulation for Proliferative Diabetic Retinopathy: the CLARITY Non-inferiority RCT. Southampton, UK: NIHR Journals Library; 2018
- 92 Flaxel CJ, Adelman RA, Bailey ST. et al. Diabetic Retinopathy Preferred Practice Pattern®. Ophthalmology 2020; 127 (01) P66-P145
