PURPOSE: To determine how the rates of diabetic retinal disease (DRD) and its vision-threatening components (VTDR), diabetic macular edema (DME), and proliferative diabetic retinopathy (PDR) among patients with diabetes mellitus (DM) have changed over the past 20 years. DESIGN: Retrospective cohort study. PARTICIPANTS: All DM patients insured by commercial and Medicare Advantage insurance plans in a claims database from 2000 through 2022 and at least 1 full calendar year of data. Cohorts were created using International Classification of Diseases codes to determine the yearly prevalence and incidence of DRD, VTDR, DME, and PDR. METHODS: Logistic and Poisson regression models created prevalence and incidence estimates, respectively. MAIN OUTCOME MEASURES: DRD, DME, and PDR prevalence and incidence. RESULTS: The prevalence of DRD initially decreased from 2002 (13.6%) to 2007 (10.9%), but then increased every year through 2021 (20.8%
P <
0.002, adjusted test for trend [aTT]). Incidence of DRD varied considerably, ranging from 16.9 cases per 1000 patient-years in 2013 to its highest of 32.2 cases per 1000 patient-years in 2021 (P <
0.002, aTT). The prevalence of VTDR and DME trended similarly, with increases from 2007 (VTDR, 5.2%
DME, 3.2%) through 2016 (VTDR, 7.5%
DME, 5.4%), followed by decreases each year through 2021 (VTDR, 6.9%
DME, 4.9%
P <
0.002, aTT). The VTDR and DME incidence rates peaked in 2009 (VTDR, 12.4 cases per 1000 patient-years
DME, 8.6 cases per 1000 patient-years) and decreased through 2022 (VTDR, 6.1 cases per 1000 patient-years
DME, 5.0 cases per 1000 patient-years
P <
0.002, aTT, for both VTDR and DME). Prevalence of PDR varied between 3.2% and 4.0% throughout the 20-year observation period (P <
0.002, aTT). Incidence of PDR decreased over time to 2.6 cases per 1000 patient-years in 2022 (P <
0.002, aTT). CONCLUSIONS: DRD prevalence (through 2007) and incidence (through 2014) initially decreased, but the rate of each has doubled since. Despite increases in DRD, incidence rates of VTDR, DME, and PDR have improved dramatically over the past 20 years. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.