Approach Considerations

Important aspects of workup regarding diabetic retinopathy include fasting glucose and hemoglobin A1c, fluorescein angiography, optical coherence tomography, and B-scan ultrasonography.

Fasting Glucose and Hemoglobin A1c

Fasting glucose and hemoglobin A1c (HbA1c) are important laboratory tests that are performed to help diagnose diabetes. The HbA1c level is also important in the long-term follow-up care of patients with diabetes and diabetic retinopathy.

The Data From an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) Study evaluated diabetic retinopathy in 235 individuals with diabetes and 227 individuals with impaired fasting plasma glucose levels.^[32]The study found that the risk of developing diabetic retinopathy at 10 years was higher in individuals with a fasting plasma glucose level of more than 108 mg/dL and HbA1c level of more than 6%. Controlling diabetes and maintaining the HbA1c level in the 6-7% range are the goals in the optimal management of diabetes and diabetic retinopathy. If the levels are maintained, then the progression of diabetic retinopathy is reduced substantially, according to The Diabetes Control and Complications Trial.

Fluorescein Angiography

Fluorescein angiography is an invaluable adjunct in the diagnosis and management of diabetic retinopathy. Microaneurysms appear as pinpoint hyperfluorescent lesions in early phases of the angiogram and typically leak in the later phases of the test.

Blot and dot hemorrhages can be distinguished from microaneurysms as hypofluorescent rather than hyperfluorescent. Areas of nonperfusion appear as homogeneous hypofluorescent or dark patches bordered by occluded blood vessels.

Intraretinal microvascular abnormalities are evidenced by collateral vessels that do not leak, usually found in the borders of the nonperfused retina. Neovascular tufts leak dye because of their high permeability; they start as hyperfluorescent areas that increase in size and intensity in the later phases of the test. (See the images below.)

Fluorescein angiogram demonstrating an area of capillary nonperfusion (arrow).

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Fluorescein angiogram demonstrating foveal dye leakage caused by macular edema.

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An area of neovascularization that leaks fluorescein on angiography.

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Optical Coherence Tomography

Optical coherence tomography (OCT) uses light to generate a cross-sectional image of the retina. This is used to determine the thickness of the retina and the presence of swelling within the retina as well as vitreomacular traction. This test is particularly used for the diagnosis and management of diabetic macular edema or clinically significant macular edema.

B-scan Ultrasonography

B-scan ultrasonography can be used to evaluate the status of the retina if the media is obstructed by vitreous hemorrhage.

Treatment & Management

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Media Gallery

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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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: Nothing to disclose.

Coauthor(s)

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.

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.

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 Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

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

Chief Editor

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, 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.