Diabetes mellitus (DM) is of increasing public health importance in India. The magnitude has been increasing over the past three decades. DM is associated with major microvascular complications among which diabetic retinopathy (DR) is emerging as one of the leading causes of visual impairment in low and middle income countries. Two-thirds of the Indian population resides in rural areas where access to modern medicine is limited mostly to the public health system. Operational guidelines are critical in delivering program components effectively. They provide the template to benchmark service delivery and help in improving quality of care. A pilot initiative to reduce visual impairment in people with diabetes was supported by an international nongovernmental funding organization over a 5-year period in India. This initiative facilitated the development of operational guidelines for DR. The guidelines were developed through consensus and primarily addressed the public health system in India.