Makindo Medical Notes

📊 Stages of Diabetic Retinopathy – At a Glance

Stage	Key Features	Investigations	Management
1️⃣ Background DR 👓	Microaneurysms Small “dot/blot” haemorrhages Hard exudates	Fundus photo, slit-lamp exam	Optimise HbA1c, BP, lipids Annual screening
2️⃣ Non-Proliferative DR 🔬	Cotton wool spots Venous beading IRMA (intraretinal microvascular abnormalities)	Fundoscopy ± fluorescein angiography; OCT for macular oedema	Systemic control Anti-VEGF or focal laser for DME Review 3–6 months
3️⃣ Proliferative DR 🚨	Neovascularisation (disc/retina) Preretinal/vitreous haemorrhage Fibrous proliferation → detachment	Fundoscopy, OCT, fluorescein angiography	Panretinal photocoagulation (PRP) Anti-VEGF adjunct Vitrectomy if persistent haemorrhage
4️⃣ Macular Oedema 🎯	Macular thickening Blurred/distorted central vision	OCT (gold standard), fluorescein angiography	Anti-VEGF (first-line) Steroid injections if refractory Focal/grid laser in some
5️⃣ Advanced Disease ⚡	Tractional retinal detachment Recurrent vitreous haemorrhage Neovascular glaucoma	OCT, fundus photography, fluorescein angiography	Vitrectomy ± anti-VEGF Glaucoma management Lifelong ophthalmology follow-up

Diabetic retinopathy (DR) is the commonest cause of blindness in working-age adults in the UK. It results from chronic hyperglycaemia damaging retinal microvasculature. As progression is often silent until advanced disease, the NHS Diabetic Eye Screening Programme (DESP) provides annual retinal photography for all people with diabetes ≥12 years.

🔬 Pathophysiology

• Hyperglycaemia → sorbitol accumulation, oxidative stress, basement membrane thickening.
• Loss of pericytes → weakened capillary walls → microaneurysms.
• Capillary leakage → retinal haemorrhages, exudates, oedema.
• Capillary closure → ischaemia → VEGF release → neovascularisation.
• New fragile vessels → haemorrhage, fibrosis, tractional retinal detachment.

📊 Stages of Diabetic Retinopathy

1️⃣ Background (Mild Non-Proliferative)

• Features: Microaneurysms, “dot/blot” haemorrhages, hard exudates. Usually asymptomatic.
• Assessment: Fundus photography, slit-lamp exam.
• Management: Optimise glycaemic (HbA1c < 7%) & BP control, annual screening, lifestyle advice.

2️⃣ Moderate/Severe Non-Proliferative DR

• Features: Cotton wool spots (nerve fibre infarcts), venous beading, IRMA (intraretinal microvascular abnormalities).
• Assessment: Retinal exam ± fluorescein angiography; OCT to detect macular oedema.
• Management: Strict systemic control, anti-VEGF injections or focal/grid laser for macular oedema, review every 3–6 months.

3️⃣ Proliferative DR (PDR)

• Features: Neovascularisation at disc or elsewhere, preretinal/vitreous haemorrhage, fibrovascular proliferation → tractional retinal detachment.
• Assessment: Fundoscopy, OCT, fluorescein angiography.
• Management: Panretinal photocoagulation (PRP), intravitreal anti-VEGF, vitrectomy for non-clearing haemorrhage/detachment. Review 3-monthly.

4️⃣ Diabetic Macular Oedema (DME)

• Features: Central vision loss, blurred/distorted vision from macular thickening.
• Assessment: OCT = gold standard; fluorescein angiography to localise leakage.
• Management: Intravitreal anti-VEGF (first-line), intravitreal steroids if refractory, focal/grid laser in some cases.

5️⃣ Advanced Diabetic Eye Disease

• Features: Recurrent vitreous haemorrhage, tractional detachment, neovascular glaucoma.
• Management: Vitrectomy, combined anti-VEGF + surgery, palliative options in end-stage disease.

🚨 Red Flags

• Sudden painless vision loss (vitreous haemorrhage or retinal detachment).
• Neovascular glaucoma (painful red eye + ↑ IOP).
• Rapidly progressive disease in type 1 diabetes, pregnancy, or poor control.

📝 Exam Pearls

• First sign: Microaneurysms.
• Main cause of vision loss: Diabetic macular oedema.
• Most urgent stage: Proliferative DR (risk of haemorrhage/detachment).
• Prevention is key: Optimising HbA1c, BP, and lipids reduces progression by >30%.
• UK context: Annual DESP screening detects DR before symptoms arise.