Nonproliferative DR

No Retinopathy No Retinal Leisions

Microaneurysms only No lesions other than microaneurysms

Mild NPDR Microaneurysms plus retinal

hemorrhage, hard exudate
Moderate NPDR Mild NPDR plus cotton wool spots and/or IRMA

Severe NPDR Presence of one of the following features:

-Microaneurysms plus venous

beading and/ or H
-Standard photo 2A in 4 quadarents,
or marked venous beading in 2 or
more quadrants or moderate IRMA
(standard photo 8A in one or more
quadrants)

Very severe NPDR Two or more of the above features described in

severe NPDR
 Proliferative DR
PDR without High Risk New Vessels and/or fibrous
Charactristics proliferations; or preretinal and/or
vitreous hemorrhage
PDR with HRC NVD Standard photo 10A; or less
extensive NVD, if vitreous or preretinal
hemorrhage is present; NVE equal to or
more than half disc area, if vitreous or
preretinal hemorrhage is present

Advanced PDR Extensive vitreous hemorrhage

precluding grading, retinal detachment
involving the macula, or pthisis bulbi
or enucleation secondary to a
complication of DR
Microaneurysms

 Earliest clinical sign of diabetic retinopathy

 Secondary to capillary wall outpouching due to
pericyte loss
 Appear as small red dots in the superficial retinal
layers
 Rupture produces blot/flame 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
 Appear similar to microaneurysms if they are small;
may need fluorescein angiography to distinguish
between the two
Flame-shaped hemorrhages

 Splinter hemorrhages that occur in the more

superficial nerve fiber layer
Retinal edema and hard exudates

 Caused by the breakdown of the blood-retina barrier,

allowing leakage of serum proteins, lipids, and protein
from the vessels
Cotton-wool spots

 Nerve fiber layer infarction from occlusion of

precapillary arterioles
 Fluorescein angiography - No capillary perfusion
 Frequently bordered by microaneurysms and vascular
hyperpermeability
Venous loops, venous beading

 Frequently adjacent to areas of nonperfusion

 Reflects increasing retinal ischemia
 Most significant predictor of progression to PDR
Intraretinal microvascular abnormalities

 Remodeled capillary beds without proliferative

changes
 Collateral vessels that do not leak on fluorescein
angiography
 Usually can be found on the borders of the
nonperfused retina
 Macular edema
 Possibly due to functional damage and necrosis of
retinal capillaries
 Clinically significant macular edema (CSME) is defined
as any of the following:
 Retinal thickening located 500 micron or less from the
center of the foveal avascular zone (FAZ)
 Hard exudates with retinal thickening 500 micron 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
Neovascularization

 Hallmark of PDR
 Most often occurs near the optic disc
(neovascularization of the disc [NVD])
 or elsewhere (neovascularization elsewhere [NVE])
Preretinal or vitreous hemorrhage

 Preretinal hemorrhages appear as pockets of blood

within the potential space between the retina and the
posterior hyaloid face. As the blood pools within this
space, they may appear boat shaped.
 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.
 Traction retinal detachments usually appear tented
up, immobile, and concave compared to
rhegmatogenous retinal detachments, which are
bullous, mobile, and convex. However, a
combination of both mechanisms is not an
uncommon finding.
Macular edema

 Leading cause of visual impairment in patients with diabetes

 Possibly due to 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 (RPE).
 CSME is defined as any of the following:
 Retinal thickening located 500 microns or less from the center of the
foveal avascular zone (FAZ)
 Hard exudates with retinal thickening 500 microns 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
Grading Severity of Retinopathy in Research

 Standard Photographs See Link