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A Practical Manual of Diabetic Retinopathy Management
This practical clinical manual covers the diagnosis, treatment - both medical and surgical - and long-term management of eye problems in people with diabetes. Aimed at the MDT involved in the care of patients with diabetes, it emphasizes the importance of regular screening and early diagnosis and presents evidence-based guidance.
214 pages, Hardcover
First published January 1, 2009
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July 24, 2025
The prevalence of diabetes is higher in men than in women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people over 65 years of age
a tight blood pressure control policy reduces the risk of clinical complications from diabetic eye disease
at least 5% of eyes receiving optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars plana vitrectomy
People with diabetes can develop an acquired colour vision defect (typically a blue loss initially) before showing any significant features of diabetic retinopathy
The fluorescein dye also gives a false high glucose reading on self-testing of the urine and blood. Patients should be warned not to adjust their insulin dose on the basis of 6 Chapter 1 their self-testing results for 48 hours after the fluorescein angiogram.
Photocoagulation (photothermal effect) Photocoagulation causes denaturation of proteins when temperatures rise sufficiently. The temperature rise in tissues is proportional to the amount of light absorbed by that tissue. The retinal pigment epithelium absorbs light because of its melanin content, and blood vessels absorb light because of their haemoglobin content
Photodisruption (photoionizing effect) Short-pulsed, high-power lasers disrupt tissues by delivering irradiance to tissue targets such as the peripheral iris producing a laser iridotomy
Photoablation (photochemical effect) Tissue is removed in some way by light, such as when intermolecular bands of biological tissues are broken, disintegrating target tissues, and the disintegrated molecules are volatilized. The excimer laser uses photoablation in photorefractive procedures such as photorefractive keratectomy
Type 2 diabetes is common – 20 times as common as type 1 diabetes – and has an obscure pathophysiology
Many theories have been propounded: lipotoxicity, glucose toxicity, amyloidosis secondary to islet-associated polypeptide beta-pleating and insulin resistance are all currently under close scrutiny
About 2% of all diabetes appears similar to type 2 diabetes but is diagnosed in the teenage years and early 20s – this has been given the oxymoron ‘maturity-onset diabetes of the young’ or ‘MODY’
There is evidence that elevated serum lipids are associated with macular exudate and prevention of moderate visual loss and partial regression of hard exudates may be possible by reducing elevated lipid levels
light being ‘focused’ at or around the fovea will not be adversely affected by any retinal structures or blood vessels before its presentation to the densely packed foveal cone photoreceptors.
The injected fluorescein sodium salt preparation is water soluble (unlike fluorescein itself) and also quickly starts to bind to and be absorbed by plasma proteins
A summary of the normal course of timing of fluorescein events is:
0 s injection of fluorescein into arm
6–10 s choroidal flush (prearterial phase)
8–12 s arterial stage
12–15 s maximum capillary transition stage
15–20 s early venous stage (lamellar or early arteriovenous stage)
20–40 s venous stage (late arteriovenous stage)
3–10 min late staining
30–60 min little residual retinal appearance (except in disease)
High-quality fluorescein angiography will not only reveal the vascular system visible in colour images but also delineate and permit the examination of ocular vessels as small as individual retinal capillaries
Macular traction can also occur from contracture of fibrotic proliferations, particularly as new vessels regress after panretinal photocoagulation, and also from a taut posterior hyaloid. If macular traction is severe, surgical intervention is required
The earliest sign of mild non-proliferative diabetic retinopathy (mild NPDR) or background DR is microaneurysms
Microaneurysms in increasing numbers have been shown to be an important early measure of progression of diabetic retinopathy. Hard exudates (sometimes now just referred to as exudates) are not a good marker of retinal ischaemia. Cotton wool spots (referred to as soft exudates in the ETDRS, a term that is now rarely used) are fluffy white opaque areas caused by an arteriolar occlusion in an area of retina resulting in an accumulation of axoplasm in the nerve fibre layer. Despite this being the underlying cause they are not a good sign of increasing retinal ischaemia
The ETDRS ‘4:2:1 rule’ indicates that the presence of severe haemorrhages in 4 quadrants (≥20), or VB in 2 quadrants, or IRMA in a single quadrant represents severe non-proliferative DR
Extensive neovascularization in the anterior chamber angle is an urgent indication for scatter laser photocoagulation,
Regression of neovascularization was associated with greater areas of retinal ablation at the initial treatment session
Panretinal laser treatment should be spaced over a minimum of two sessions unless there is a strong suspicion that the individual being treated might not attend for subsequent treatment sessions.
Scatter laser treatment should not be delayed when the risk of vitreous haemorrhage or neovascular glaucoma seems high regardless of the status of the macula.
In young patients with IDDM who have aggressive peripheral ischaemia associated with diffuse or cystoid macular oedema, commence panretinal photocoagulation before treating the macula to see if this resolves following panretinal photocoagulation.
chronic oedema tends to cause pigment epithelial changes relating to damage to the photoreceptors in the central fovea and permanent loss of vision
The major surgical goal in vitrectomy for PDR is to separate and excise the posterior cortical vitreous surface and associated areas of fibrovascular proliferation from the retinal surface
Blindness, compared to no visual impairment, is associated with over $2000 of excess annual medical expenditures per year and to more than 5 extra days of informal care from someone outside the household
hypertensive retinopathy can usually be differentiated as nerve-fibre layer ‘streak’ or ‘flame-shaped’ haemorrhages frequently surrounding and pointing towards the optic disc, and associated (nerve-fibre layer) cotton wool spots, also surrounding the optic disc
Diabetic retinopathy is a microvascular disease. However, people with diabetes are also more liable to develop disease of the larger vessels (macrovascular disease) than a person without diabetes
a tight blood pressure control policy reduces the risk of clinical complications from diabetic eye disease
at least 5% of eyes receiving optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars plana vitrectomy
People with diabetes can develop an acquired colour vision defect (typically a blue loss initially) before showing any significant features of diabetic retinopathy
The fluorescein dye also gives a false high glucose reading on self-testing of the urine and blood. Patients should be warned not to adjust their insulin dose on the basis of 6 Chapter 1 their self-testing results for 48 hours after the fluorescein angiogram.
Photocoagulation (photothermal effect) Photocoagulation causes denaturation of proteins when temperatures rise sufficiently. The temperature rise in tissues is proportional to the amount of light absorbed by that tissue. The retinal pigment epithelium absorbs light because of its melanin content, and blood vessels absorb light because of their haemoglobin content
Photodisruption (photoionizing effect) Short-pulsed, high-power lasers disrupt tissues by delivering irradiance to tissue targets such as the peripheral iris producing a laser iridotomy
Photoablation (photochemical effect) Tissue is removed in some way by light, such as when intermolecular bands of biological tissues are broken, disintegrating target tissues, and the disintegrated molecules are volatilized. The excimer laser uses photoablation in photorefractive procedures such as photorefractive keratectomy
Type 2 diabetes is common – 20 times as common as type 1 diabetes – and has an obscure pathophysiology
Many theories have been propounded: lipotoxicity, glucose toxicity, amyloidosis secondary to islet-associated polypeptide beta-pleating and insulin resistance are all currently under close scrutiny
About 2% of all diabetes appears similar to type 2 diabetes but is diagnosed in the teenage years and early 20s – this has been given the oxymoron ‘maturity-onset diabetes of the young’ or ‘MODY’
There is evidence that elevated serum lipids are associated with macular exudate and prevention of moderate visual loss and partial regression of hard exudates may be possible by reducing elevated lipid levels
light being ‘focused’ at or around the fovea will not be adversely affected by any retinal structures or blood vessels before its presentation to the densely packed foveal cone photoreceptors.
The injected fluorescein sodium salt preparation is water soluble (unlike fluorescein itself) and also quickly starts to bind to and be absorbed by plasma proteins
A summary of the normal course of timing of fluorescein events is:
0 s injection of fluorescein into arm
6–10 s choroidal flush (prearterial phase)
8–12 s arterial stage
12–15 s maximum capillary transition stage
15–20 s early venous stage (lamellar or early arteriovenous stage)
20–40 s venous stage (late arteriovenous stage)
3–10 min late staining
30–60 min little residual retinal appearance (except in disease)
High-quality fluorescein angiography will not only reveal the vascular system visible in colour images but also delineate and permit the examination of ocular vessels as small as individual retinal capillaries
Macular traction can also occur from contracture of fibrotic proliferations, particularly as new vessels regress after panretinal photocoagulation, and also from a taut posterior hyaloid. If macular traction is severe, surgical intervention is required
The earliest sign of mild non-proliferative diabetic retinopathy (mild NPDR) or background DR is microaneurysms
Microaneurysms in increasing numbers have been shown to be an important early measure of progression of diabetic retinopathy. Hard exudates (sometimes now just referred to as exudates) are not a good marker of retinal ischaemia. Cotton wool spots (referred to as soft exudates in the ETDRS, a term that is now rarely used) are fluffy white opaque areas caused by an arteriolar occlusion in an area of retina resulting in an accumulation of axoplasm in the nerve fibre layer. Despite this being the underlying cause they are not a good sign of increasing retinal ischaemia
The ETDRS ‘4:2:1 rule’ indicates that the presence of severe haemorrhages in 4 quadrants (≥20), or VB in 2 quadrants, or IRMA in a single quadrant represents severe non-proliferative DR
Extensive neovascularization in the anterior chamber angle is an urgent indication for scatter laser photocoagulation,
Regression of neovascularization was associated with greater areas of retinal ablation at the initial treatment session
Panretinal laser treatment should be spaced over a minimum of two sessions unless there is a strong suspicion that the individual being treated might not attend for subsequent treatment sessions.
Scatter laser treatment should not be delayed when the risk of vitreous haemorrhage or neovascular glaucoma seems high regardless of the status of the macula.
In young patients with IDDM who have aggressive peripheral ischaemia associated with diffuse or cystoid macular oedema, commence panretinal photocoagulation before treating the macula to see if this resolves following panretinal photocoagulation.
chronic oedema tends to cause pigment epithelial changes relating to damage to the photoreceptors in the central fovea and permanent loss of vision
The major surgical goal in vitrectomy for PDR is to separate and excise the posterior cortical vitreous surface and associated areas of fibrovascular proliferation from the retinal surface
Blindness, compared to no visual impairment, is associated with over $2000 of excess annual medical expenditures per year and to more than 5 extra days of informal care from someone outside the household
hypertensive retinopathy can usually be differentiated as nerve-fibre layer ‘streak’ or ‘flame-shaped’ haemorrhages frequently surrounding and pointing towards the optic disc, and associated (nerve-fibre layer) cotton wool spots, also surrounding the optic disc
Diabetic retinopathy is a microvascular disease. However, people with diabetes are also more liable to develop disease of the larger vessels (macrovascular disease) than a person without diabetes
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