Diabetic retinopathy (DR) is a leading cause of blindness despite advances in treatment and there remains an unmet need for low-cost interventions to prevent and slow the progression of DR. Fenofibrate has shown promise as a useful adjunct in DR management and is licensed for use in the treatment of DR in a few countries. However, the data supporting the use of fenofibrate for the treatment of DR emerged from subsidiary analyses of the FIELD, ACCORD-LIPID and its sub-study ACCORD-EYE trials, which were primarily designed to evaluate cardiovascular outcomes. The recently concluded LENS trial, designed to evaluate the effect of fenofibrate on progression of DR, has shown clear evidence of benefit over medium-term follow-up (i.e., 4–5 years), and confirmed its safety in people with type 1 or type 2 diabetes. These benefits appear to be independent of fenofibrate's lipid lowering effects and are more likely to be mediated via its direct effects on the eye. In this narrative review on the use of fenofibrate in the treatment of DR, we summarise the possible mechanisms of action, existing evidence from randomised trials, and implications for clinical practice and research.