Instructor of Pediatrics and Ophthalmology

Discussion and Pictures of Diabetic Retinopathy Lesions

The information contained on this web page is geared towards educating patients, the
general public and providing basic knowledge to healthcare providers on diabetic
retinopathy and its effects on the visual system.

Non-Proliferative Lesions
Although non-proliferative lesions can range from very mild to very severe, they typically
do not require treatment (with the exception of "clinically significant macular edema"
(CSME) - discussed in the hard exudate section below). Determining the severity of
diabetic retinopathy is difficult, but in general, what determines the severity of retinopathy
is the extent or physical area the following lesions encompass. All retinal photographs
below are standard photographs from the Early Treatment of Diabetic Retinopathy Study
(ETDRS), which are used as the gold standard for grading severity in the clinical and
research arena.

*Academic note for healthcare providers: Underlined portions within the discussion of
these lesions are references to anatomical position within the retina. The anatomical
location of these lesions is crucial for differentiation of non-proliferative vs. proliferative
lesions (hemorrhages vs. preretinal hemorrhages and IRMA vs. NVE in particular).

Microaneurysms (Ma’s) – Ma’s are the first lesions appearing in diabetic retinopathy. Ma’s
are physical dilations of the smallest intra-retinal blood vessels called capillaries. These
lesions appear as small circular, red dots having distinct margins and are no larger than a
blood vessel width at the disk margin. Good examples are seen in the following standard
photograph 1:

Figure 1. ETDRS Standard Photograph 1 showing Ma’s: Concentrate on the smallest

red spots in the middle of the photo.

Retinal Hemorrhages (H’s) – These lesions represent actual bleeding within the retina, and
either are a result of ruptured Ma’s or when the above-mentioned capillaries become leaky
enough to let blood out of the blood vessels (just as when we get a cut on our skin). These
hemorrhages can be a variety of shapes including dot, blot and flame-shaped. They are
usually larger than Ma’s (equal to or larger than a blood vessel at the disk margin), with
uneven/indistinct edges and coloring. See the below standard photograph 2a: and
concentrate on the larger red spots within the photograph.

Figure 2. ETDRS Standard photograph 2a showing H/Ma’s: Concentrate on the larger

red spots within the photograph. You may see some Ma’s in this photograph as well. This
is because Ma’s and H’s commonly occur together (H/Ma’s).

Hard Exudates (HE’s) – These are white/yellow cholesterol deposits that usually originate
from leaking Ma’s. HE’s are irregularly shaped, vary in size, are hard edged and often have
a "fatty" appearance. HE can, and often are associated with fluid accumulation (retinal
edema) within the retina.

* HE and associated edema can occur adjacent to the macula, the part of the retina
responsible for detailed, central vision. When the edema spreads into or very close the
macula (clinically significant macular edema (CSME)), central vision can be affected and
will cause the central vision to become constantly blurry. CSME can occur at any stage of
retinopathy (non-proliferative or proliferative stages), and is usually treated with laser.

Figure 3. ETDRS Standard photograph 4 showing HE’s in macula.

Soft Exudates (SE) – aka "Cotton Wool Spots" - these lesions appear as white, feathery,
fluffy or "cottony" spots. SE’s physically represent infarcts, or closures of capillaries,
within the retina; however the physical locations of these lesions are in the very exterior
layer of the retina (in the nerve fiber layer). Cotton Wool Spots often occur in association
with IRMA (discussed below).
Figure 4. ETDRS standard photograph 5 showing SE: Concentrate on the white areas
just above the very center of the photo, at 3 o’clock (extreme right side of photo) and at
9:30 (just above the extreme left side of the photo).

Intraretinal Microvascular Anomalies (IRMA) – Occurring in the mid to late stages of non-
proliferative retinopathy, these appear as spidery abnormal vessels that appear within the
retina. They are typically contorted in appearance with sharp corners, often crossing over
themselves and they normally do not cross over major veins or arteries. It is thought that
IRMA physically represents either dilation of pre-existing capillaries or actual growth of
new blood vessels within the retina.

Figure 5. ETDRS standard photograph 6B Showing IRMA and VB:

IRMA - Concentrate on the center of the photograph at the small spidery blood vessels –
Early IRMA is very subtle, but this is a classic example of obvious and advanced IRMA.
VB - Concentrate on the major vessel as it passes through the center of the photo and
courses to the left (9 o’clock position). This area of the photo represents obvious VB,
where both walls of this vessel cave inward to form small, local constrictions in the vein.

Venous Beading (VB) – Also occurring in the late stages of non-proliferative disease, VB
occurs when the walls of major retinal veins loose their normal parallel alignment and
begin to appear more like a string of sausages. Physically, IRMA represents a situation in
which vein walls loose their elasticity and localized areas begin to dilate. This lesion is one
of the strongest predictors of progression to proliferative disease. The above standard
photograph represents this phenomenon very well.
Proliferative Lesions
Proliferative lesions are advanced signs of diabetic retinopathy and in general, require
treatment as well as close follow up. The aim of treatment in this stage of disease to reduce
the retina’s need for oxygen and nutrients, which will cause these proliferative lesions to
regress and prevent severe vision loss.

New vessels (on the disc, NVD – or elsewhere, NVE) – aka "neovascularization"– NV are
the first of the proliferative lesions to appear. The thought is that the retina is experiencing
areas of hypoxia, or is "under-nourished". In an effort to compensate for this problem, the
eye grows new vessels in the areas lacking circulation. The new vessels are very delicate
and grow on top of the retina rather than in it, making them prone to leaking and
hemorrhaging. They can cross over one or many major retinal blood vessels, but tend not to
cross over themselves. They will often appear in a blossom like a flower bud with the
outside part of the NV more dilated than the inner NV. They can also appear as stringy and
drawn out, but this is less common.

Figure 6. ETDRS standard Figure 7. ETDRS standard

photograph 10C showing NVD. photograph 7 showing NVE.

Note: Notice how the most peripheral vessels are the most dilated on both NVD and NVE
and how these fine vessels cross major blood vessels of the retinal multiple times. Also
these lesions obscure underlying structures, which indicates that they are on top or before
the retina and not within it.

Fibrous proliferation (on the disc, FPD - or elsewhere, FPE) - After the appearance of NV,
the eye wants to protect these new vessels and give them support and structure to grow on.
A white fibrous tissue grows either adjacent to or intertwined with the new vessels. This FP
is very "sticky" and tends to adhere to the retina and NV. These adhesions can accidentally
pull the NV and cause them to hemorrhage or can pull on the retinal and cause it to detach.
Figure 8. ETDRS standard Figure 9. ETDRS standard
photograph 11 showing FPE with photograph 15 showing FPD with
associated NVE associated NVD

Preretinal and vitreous hemorrhage (PRH, VH) – Occurs when the delicate NV leaks blood
or is broken by the traction of fibrous proliferations. These two lesions are separated in
name by their anatomical location. If this blood leaks into the potential space between the
retinal and the internal limiting membrane, which lines the surface of the retina, it is called
a preretinal hemorrhage. If the blood leaks into the vitreous or the posterior chamber, it is
called a vitreous hemorrhage.

Figure 10. ETDRS standard photograph 13 demonstrating a preretinal hemorrhage.

Note how the heme obscures the major blood vessels, which indicates that its placement in
before the retina (thus preretinal heme).

Acknowledgments:

1. Wisconsin Epidemiologic Study of Diabetic Retinopathy; Stacy Meuer, Ronald

Klein and Barbara Klein at the University of Wisconsin Department of
Ophthalmology who provided most of the text included in this discussion.

2. Early Treatment of Diabetic Retinopathy Study (ETDRS) research group who

developed all of the standard photos used in this discussion.