Background <p>Diabetic retinopathy (DR) is a leading cause of acquired blindness, characterized by degeneration and injury of retinal ganglion cells (RGCs). This study focuses on the impacts and mechanisms of exosomes from adipose-derived stem cells (ADSC-Exos) on RGC injury in DR.</p> Methods <p>ADSCs were cultured in vitro and ADSC-Exos were isolated using ultracentrifugation. DR mouse models were established and treated with ADSC-Exos, NLRP3 inflammasome activator Nigericin, or Nrf2 inhibitor ML385 to assess the effects of ADSC-Exos on retinopathy symptoms and microglial characteristics. Microglia (BV2) were stimulated with high glucose (HG, 35 mM) to mimic the diabetic damage condition in vitro and treated with ADSC-Exos and ML385. RGCs were cultured in the above BV2 cell-conditioned medium, with their viability and apoptosis evaluated using MTT and flow cytometric analyses. Nrf2 and HO-1 protein levels and the inflammation-related proteins were measured post co-culture.</p> Results <p>ADSC-Exos alleviated NLRP3 inflammasome activation in mouse retinal tissue, M1 polarization and pyroptosis of microglia to reduce apoptosis of RGCs, while such effects were partly reversed by the activation of NLRP3 inflammasome. In vitro, ADSC-Exos inhibit NLRP3 inflammasome activation, thereby reducing HG-induced M1 polarization and pyroptosis in BV2 cells. Furthermore, the resulting culture supernatant effectively attenuates RGC apoptosis. Moreover, ADSC-Exos promoted the Nrf2/HO-1 pathway activation in HG-induced BV2 cells, whereas such effect can be partially reversed by inhibiting the Nrf2/HO-1 pathway.</p> Conclusions <p>ADSC-Exos suppress NLRP3 inflammasome activation by activating the Nrf2/HO-1 pathway to reduce HG-caused microglial pyroptosis, thereby mitigating retinal inflammation and decreasing RGC apoptosis in DR mice.</p>