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Diabetic Retinopathy Clinical Presentation

  • Author: Abdhish R Bhavsar, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Jul 31, 2016
 

History

In the initial stages of diabetic retinopathy, patients are generally asymptomatic; in the more advanced stages of the disease, however, patients may experience symptoms that include floaters, blurred vision, distortion, and progressive visual acuity loss.

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Physical Examination

The mainstay of diagnosing diabetic retinopathy is a complete ophthalmic examination and dilated retinal examination by an ophthalmologist or retina specialist or retina surgeon.

Outreach screening has the potential to increase screening coverage of high-risk patients with diabetic retinopathy in remote and resource-poor settings or in areas in which no ophthalmologist or retina specialist is available, without the risk of missing diabetic retinopathy and the opportunity to prevent vision loss.[23]

Microaneurysms

Microaneurysms are the earliest clinical sign of diabetic retinopathy and occur secondary to capillary wall outpouching due to pericyte loss. They appear as small red dots in the superficial retinal layers, and there is fibrin and red blood cell accumulation in the microaneurysm lumen. A rupture produces blot/flame hemorrhages. Affected areas may appear yellowish in time, as endothelial cells proliferate and produce basement membrane.

Dot and blot hemorrhages

Dot and blot hemorrhages occur as microaneurysms rupture in the deeper layers of the retina, such as the inner nuclear and outer plexiform layers. These appear similar to microaneurysms if they are small; fluorescein angiography may be needed to distinguish between the two.

Flame-shaped hemorrhages

Flame-shaped hemorrhages are splinter hemorrhages that occur in the more superficial nerve fiber layer.

Retinal edema and hard exudates

Retinal edema and hard exudates are caused by the breakdown of the blood-retina barrier, allowing leakage of serum proteins, lipids, and protein from the vessels.

Cotton-wool spots

Cotton-wool spots are nerve fiber layer infarctions from occlusion of precapillary arterioles. With the use of fluorescein angiography, there is no capillary perfusion. These are frequently bordered by microaneurysms and vascular hyperpermeability.

Venous loops and venous beading

Venous loops and venous beading frequently occur adjacent to areas of nonperfusion and reflect increasing retinal ischemia. Their occurrence is the most significant predictor of progression to proliferative diabetic retinopathy.

Intraretinal microvascular abnormalities

Intraretinal microvascular abnormalities are remodeled capillary beds without proliferative changes. These collateral vessels do not leak on fluorescein angiography and can usually be found on the borders of the nonperfused retina.

Macular edema

Macular edema is the leading cause of visual impairment in patients with diabetes. A reported 75,000 new cases of macular edema are diagnosed annually. This may be due to functional damage and necrosis of retinal capillaries.

Clinically significant macular edema is defined as any of the following:

  • Retinal thickening located 500 μm or less from the center of the foveal avascular zone (FAZ)
  • Hard exudates with retinal thickening 500 µm or less from the center of the FAZ
  • Retinal thickening 1 disc area or larger in size located within 1 disc diameter of the FAZ

Nonproliferative diabetic retinopathy

Mild nonproliferative diabetic retinopathy (NPDR) is indicated by the presence of at least 1 microaneurysm. Mild NPDR reflects structural changes in the retina caused by the physiological and anatomical effects of diabetes.

More advanced stages of NPDR reflect the increasing retinal ischemia, setting the stage for proliferative changes.

Moderate nonproliferative diabetic retinopathy includes the presence of hemorrhages, microaneurysms, and hard exudates. With this condition, soft exudates, venous beading, and intraretinal microvascular abnormalities (IRMA) occur less frequently than with severe NPDR.

Severe NPDR (4-2-1) is characterized by hemorrhages and microaneurysms in 4 quadrants, with venous beading in at least 2 quadrants and IRMA in at least 1 quadrant.

Proliferative diabetic retinopathy

Neovascularization is the hallmark of PDR. It most often occurs near the optic disc (neovascularization of the disc [NVD]) or within 3 disc diameters of the major retinal vessels (neovascularization elsewhere [NVE]). (See the image below.)

New vessel formation on the surface of the retina New vessel formation on the surface of the retina (neovascularization elsewhere)

Preretinal hemorrhages appear as pockets of blood within the potential space between the retina and the posterior hyaloid face. As blood pools within this space, they may appear boat shaped. (See the image below.)

Boat-shaped preretinal hemorrhage associated with Boat-shaped preretinal hemorrhage associated with neovascularization elsewhere.

Hemorrhage into the vitreous may appear as a diffuse haze or as clumps of blood clots within the gel.

Fibrovascular tissue proliferation is usually seen associated with the neovascular complex and also may appear avascular when the vessels have already regressed. (See the images below.)

Fibrovascular proliferations within the vitreous c Fibrovascular proliferations within the vitreous cavity
Extensive fibrovascular proliferations within and Extensive fibrovascular proliferations within and around the optic disc

Traction retinal detachments usually appear tented up, immobile, and concave, as compared to rhegmatogenous retinal detachments, which are bullous, mobile, and convex. A combination of both mechanisms is not an uncommon finding, however.

Macular edema is the leading cause of visual impairment in patients with diabetes. It may result from functional damage and necrosis of retinal capillaries. In cases of PDR, edema also may be caused by retinal traction if the retina is sufficiently elevated away from the retinal pigment epithelium.

Proliferative diabetic retinopathy is classified as early or high risk.[24] In early PDR, new vessels are present, but they do not meet the criteria for high-risk PDR. In high-risk PDR, NVD is one-third to one-half, or greater, of the disc area (DA); there may be any amount of NVD with vitreous or preretinal hemorrhage; and NVE is one-half or greater of the DA, with preretinal or vitreous hemorrhage.

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Contributor Information and Disclosures
Author

Abdhish R Bhavsar, MD Adjunct Assistant Professor, Department of Ophthalmology, University of Minnesota Medical School; Director of Clinical Research, Retina Center, PA; Past Chair, Consulting Staff, Department of Ophthalmology, Phillips Eye Institute

Abdhish R Bhavsar, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Minnesota Medical Association

Disclosure: Received grant/research funds from Allergan; Received grant/research funds from genentech; Received grant/research funds from regeneron; Received grant/research funds from sirion for none; Received consulting fee from Eyetech for consulting; Received consulting fee from Allergan for consulting; Received consulting fee from regeneron for consulting; Received travel reimbursement from Allergan for consulting.

Coauthor(s)

John H Drouilhet, MD, FACS Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine

John H Drouilhet, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Neal H Atebara, MD Private Practice, Retina Center of Hawaii

Neal H Atebara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Retina Society, American Medical Association, Hawaii Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, Retina Society, Club Jules Gonin

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

V Al Pakalnis, MD, PhD Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sherman O Valero, MD, to the development and writing of this article.

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Fundus photograph of early background diabetic retinopathy showing multiple microaneurysms.
Retinal findings in background diabetic retinopathy, including blot hemorrhages (long arrow), microaneurysms (short arrow), and hard exudates (arrowhead).
Fluorescein angiogram demonstrating an area of capillary nonperfusion (arrow).
Fluorescein angiogram demonstrating foveal dye leakage caused by macular edema.
Fundus photograph of clinically significant macular edema demonstrating retinal exudates within the fovea.
New vessel formation on the surface of the retina (neovascularization elsewhere)
An area of neovascularization that leaks fluorescein on angiography.
Boat-shaped preretinal hemorrhage associated with neovascularization elsewhere.
Fibrovascular proliferations within the vitreous cavity
Extensive fibrovascular proliferations within and around the optic disc
 
 
 
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