Snapshot A 47-year-old man presents with progressive worsening of his symptoms. He reports having increased bluriness that does not improve with frequent blinking or glasses. Medical history is remarkable for type II diabetes, and his last hemoglobin A1c was 11%. He is currently on metformin and insulin; however, he has been nonadherent to his medications. A dilated study was perfomed via slit-lamp examination, which demonstrated multiple dot and blot hemorrhages, microaneurysms, and hard exudates. (Nonproliferative diabetic retinopathy) Introduction Ocular manifestations for chronic hyperglycemia leading to microvascular and retinal dysfunction diabetic retinopathy is classified as nonproliferative absence of neovascularizations proliferative presence of neovascularizations Epidemiology Incidence an important cause of visual loss worldwide most common cause of preventable blindness Risk factors poorly controlled diabetes Pathophysiology Chronic hyperglycemia impairs autoregulation of retinal blood flow leads to shear stress on the retinal vasculature, resulting in production of vasoactive molecules vascular leakage macular edema Retinal microthrombosis occludes retinal capillaries and increases capillary leakage retinal ischemia leads to the release of many growth factors (e.g., VEGF) Growth factors leads to the production of new blood vessels (neovascularization) increases the risk of a vitreous hemorrhage Presentation Symptoms decreased visual acuity Physical exam nonproliferative diabetic retinopathy dot and blot hemorrhages hard exudates reflects leakage of lipids and proteinacenous materal capillary microaneurysms proliferative diabetic retinopathy neovascularization vitreous hemorrhage, if newly formed vessels rupture Studies Serum studies hemoglobin A1c Differential Hypertensive retinopathy differentiating factors arteriovenous nicking silver or copper wiring Treatment Lifestyle optimizing glycemic, lipid, and blood pressure control indication holistic management Pharmacologic intravitreal anti-vascular endothelial growth factor (VEGF) indication significant macular edema proliferative diabetic retinopathy medications bevacizumab ranibizumab aflibercept Operative panretinal photocoagulation indication significant macular edema proliferative diabetic retinopathy Complications Blindness Prognosis If untreated can progress to proliferative diabetic retinopathy