What is Diabetic Retinopathy Stages? And Why Should You Care?

Diabetic Retinopathy Stages Summary

  • Patients with mild NPDR do not need to be referred to a retina specialist unless they are concerned about or have confirmed a diagnosis of DME.
  • Patients with moderate NPDR have a 12% to 27% risk of developing PDR within 1 year and should be seen every 6 to 8 months.
  • Patients with severe NPDR have a 52% risk of developing PDR within 1 year, are at a high risk of disease progression and permanent vision loss, and are most likely experiencing neuropathy elsewhere.
What is Diabetic Retinopathy Stages? And Why Should You Care?

Diabetic Retinopathy Definition

Diabetic retinopathy is an eye disease caused by high levels of glucose in the blood. The high levels of sugar for a prolonged duration lead to complications of the eye. There are many complications caused by diabetes in the eye. There are four main diabetic retinopathy stages that can be more easily treated if detected early, especially through preventive measures.

Causes of diabetic retinopathy

There are many complications caused by diabetes in the eye. These can be divided as

Common causes:

  • Retinopathy
  • Iridopathy
  • Unstable refraction

Uncommon causes:

  • Recurrent styes
  • Xanthelasma
  • Accelerated senile cataract
  • Neovascular glaucoma
  • Ocular motor nerve palsies
  • Reduced corneal sensitivity

Rare causes:

Papillopathy, the light near dissociation, acute onset cataract, rhino orbitalMucor mycosis, etc.

One of the most common complications of diabetes in the eye is diabetic retinopathy. It is a preventable cause of blindness. In the general population, the prevalence of diabetes is 40%. It is more common in type 1 diabetes than in type 2 diabetes.

According to the American Academy of Ophthalmology, the high levels of sugar in the blood cause the vessels to swell, become leaky, and block, later on, compromising the blood supply to the retina. Early detection is the key to preventing blindness. The management of diabetic retinopathy stages depends upon the stage of retinopathy

Risk factors of diabetic retinopathy:

  • Duration of diabetes:

The duration of diabetes is the most important factor. For patients diagnosed with diabetes before the age of 30 years, the risk of developing retinopathy after 10 years is 30% while in patients diagnosed with diabetes after 30 years is 90%.

  • Poor control of diabetes:

The tight control of diabetes instituted early can prevent or delay the progression of diabetic retinopathy. However sudden tight control may be associated with the progression of retinopathy in the near term.

  • Pregnancy:

Pregnancy is sometimes associated with the progression of DR. The cause includes greater pre-pregnancy severity of DR, poor pre-pregnancy control of diabetes and pre-eclampsia. The risk is more during the first trimester. Diabetic macular edema subsides after the pregnancy and need not be treated if it develops in later pregnancy.

  • Hypertension:

Hypertension is common in diabetic patients. Control should be below 140/80. Tight control is highly beneficial in the progression of DR.

  • Nephropathy:

Nephropathy is associated with greater progression of DR. Treatment of renal disease is associated with improved retinopathy and better response to photocoagulation.

Diabetic Retinopathy Stages

Diabetic retinopathy stages develop over time.

If you’ve been diagnosed with diabetic retinopathy after a diabetic eye screening, Making lifestyle changes and getting treatment can help to improve the situation and prevent it from getting worse.

The main diabetic retinopathy stages are described below. You don’t have to experience them all. The most effective way to protect your vision from diabetic retinopathy is to maintain good control of your diabetes.

Stage 1: Mild nonproliferative diabetic retinopathy

The first stage is called background retinopathy. It is characterized by microaneurysms, dot and blot hemorrhages, and exudates. These are generally the earliest signs of diabetic retinopathy and may persist till the end. The microaneurysm is a tiny bulge in the retinal blood vessels. They are prone to leak easily. Patients in this stage have no symptoms, however, the range of review is 6-12 months, depending on the severity, systemic factors, and patient’s personal circumstances.

 Stage 2: Moderate nonproliferative diabetic retinopathy

The second stage is called pre-proliferative retinopathy. At this stage, the blood vessels swell in your retinas. They can’t take blood like they used to. These things can cause physical changes in the retina.

These changes may cause diabetic macular edema (DME). This occurs when blood and other fluids collect in a part of your retina called the macula. The macula is the key to seeing straight ahead, such as when you read or drive. When it swells, it can cause problems with your vision’s most important part. In this stage, severe retinal hemorrhages develop in 1- 3 quadrants of the retina (according to standard ETDRS charts). Severe venous beading may be present in no more than one quadrant. Review is advised in 6 months. The chance of developing proliferative diabetic retinopathy at this stage is 26%, and for high-risk proliferative diabetic retinopathy, the risk is 8% within a year.

Stage 3: Severe nonproliferative diabetic retinopathy

It is also called proliferative retinopathy. In this stage, your blood vessels become more blocked. This means that even less blood goes to the retina. This causes scar tissue to form. The loss of blood signals your retina to make new blood vessels.

If the blood vessels become completely blocked, this is called macular ischemia. This can lead to blurred vision with dark spots that some people describe as “floaters.”

The rule of 4-2-1 is followed in this stage:

  • Severe hemorrhages in all the four quadrants
  • Significant venous beading in 2 or more quadrants
  • Moderate IRMA in 1 or more quadrants

Review for patients in this stage is after every 4 months. The chance to develop proliferative diabetic retinopathy at this stage is 50%, and for high-risk proliferative diabetic retinopathy, the risk is 15% within a year.

Stage 4: Proliferative diabetic retinopathy

In this advanced stage of the disease, new blood vessels form in the retina. Because these blood vessels are often fragile, the risk of fluid leakage is high. This leads to various vision problems such as blurred vision, reduced vision, and even blindness.

Diabetic Retinopathy Abstract

Symptoms of diabetic retinopathy

What are the symptoms of diabetic retinopathy?

Diabetic retinopathy usually does not cause symptoms during the non-proliferative stages. It is very much possible to be symptomless in the initial days of retinopathy. The majority of the patients present during the proliferative stage of retinopathy. Early and regular examination of the eye in patients with risk factors will help in the early detection and reduce the risk of diabetic retinopathy-related complications.

Symptoms of proliferative diabetic retinopathy include:

  • an increased number of eye floaters
  • blurry vision
  • distorted vision
  • frequent change in glasses
  • poor night vision
  • loss of vision
  • decreased field of vision
  • change in color vision

Also, remember those diabetic retinopathy stages symptoms usually simultaneously affect both eyes.

Diagnosis of Diabetic Retinopathy

How is diabetic retinopathy diagnosed?

The patient is passed through a detailed examination of the eye for the diagnosis of diabetic retinopathy stages. It includes

  • Visual equity
  • Refraction
  • Slit lamp examination of anterior and posterior chamber
  • Intraocular pressure measurement
  • Colour vision test
  • Depth perception
  • Visual field examination

Your doctor will also likely dilate your eye using special eye drops to examine your optic nerve and retina.

Eye Doctors also diagnose diabetic retinopathy with fluorescein angiography, which checks for abnormal growth or leakage of blood vessels.

Diabetic Retinopathy Treatment

 How to treat diabetic retinopathy

General management:

Patient education is critical in the treatment of diabetic retinopathy. The need for regular review and treatment schedules should be made clear for a better outcome.

The risk factors should be controlled including diabetes, hypertension, hyperlipidemia, renal diseases and smoking should be discontinued.

Treatment of Diabetic Macular EDEMA:

In diabetic macular edema, the center of the retina, or macula, begins to swell due to fluid accumulation. Because the macula is important for accurate vision, diabetic macular edema can blur your vision.

The doctor will continue to monitor your eyes, however, to make sure the disease is not progressing.

Treatment options include injections, surgery, and laser treatments.

eye injections for diabetic retinopathy

Intravitreal anti-VEGF agents: Following substantial clinical studies, anti-VEGF has been adopted as a critical element in the management of diabetic macular edema. Different types of anti-VEGF agents are available in the market.

Anti-VEGF medications include:

  • aflibercept (Eylea)
  • bevacizumab (Avastin)
  • ranibizumab (Lucentis)

Intravitreal triamcinolone: In pseudophakic eyes, intravitreal triamcinolone steroid injection followed by laser is comparable to laser with regard to visual improvement and reducing retinal thickening.

This medication must be injected by a doctor. The doctor will numb your eye to reduce any discomfort. This treatment usually requires injections every month,

Diabetic Retinopathy Surgery

Pars plana vitrectomy: PPV is indicated in eyes associated with tangential traction from a thicken and taut posterior hyaloid. It is performed for advanced diabetic retinopathy stages.

The procedure involves the removal of traction bands and vitreous and replacement done with silicone oil or gases.

Talk to your doctor about options for keeping you comfortable during surgery. Your doctor may use medication to numb your eye or general anesthesia so that you are unconscious during the procedure.

Diabetic Retinopathy Laser Treatment

Infographic Laser Treatment Of Diabetic Macular EDEMA

Your doctor will first use a local anesthetic to keep you comfortable during the procedure. They will use medicine to dilate your pupil. Then, a laser will be used by the doctor to shine light into your eye

The first-line treatment option for diabetic macular edema includes

Laser photocoagulation:

The aim of laser photocoagulation is to burn the abnormal leaking vessels, so that fluid accumulation is controlled/ there are three types of lasers employed for this purpose.


In focal photocoagulation diode or argon, burns are applied to the leaking vessels. The spot size is kept 50-100um and the duration is 0.05-0.1s.


In grid photocoagulation, burns are applied to diffuse areas of the macula with a spot size of 50-100um and a duration of 0.05-0.1s. Subthreshold micropulse diode laser: This modality uses very short laser pulse duration and prolonged intervals. This minimizes the damage to the retina and choroid while stimulating retinal pigment epithelium.

Laser treatment can sometimes take more than one session to be effective.

Diabetic Retinopathy Laser Treatment

Treatment of Proliferative Retinopathy:

Pan retinal photocoagulation is the mainstay treatment option for proliferative diabetic retinopathy. In PRP topical or local anesthesia is given to the patient. Retinal burns of 400um and duration of 0.50-0.1s with argon laser are applied. The procedure can be associated with a reduction in peripheral vision and problems with color vision. Patients who drive should be made aware of the complications of the procedure.

Prevent diabetic retinopathy

What are ways to prevent diabetic retinopathy?

Prevention of diabetic retinopathy starts with blood sugar management.

You will need to take medication for your diabetes, eat a balanced diet, and exercise regularly. You will also need to check your blood sugar regularly and talk to your doctor if your blood sugar levels are difficult to control.

A healthy diet consists of:

  • low glycemic carbohydrates
  • Fruits
  • Vegetables
  • Whole grains
  • Legumes
  • Low-fat dairy
  • Healthy fats (avocados and nuts)
  • Heart-healthy fish, such as salmon and tuna

Diabetes management may involve other changes. This may include controlling your blood pressure and cholesterol and avoiding tobacco.

Complications of diabetic retinopathy

Advanced diabetic eye disease is a serious vision-threatening complication of diabetic retinopathy and occurs in patients in whom the treatment is inadequate or unsuccessful. This includes

  1. Hemorrhage: The leaking blood vessels in the retina may cause bleeding in preretinal, intragel, or both parts of the retina.
  2. Tractional retinal detachment: It is caused by the progressive contraction of fibrovascular membranes over areas of vitreoretinal attachments
  3. Rubeosis iridis: It is common in eyes with severe ischemia or persistent retinal detachment. If severe, rubeosis iris can lead to neovascular glaucoma.
Indications for pars plana vitrectomy:
  • PPV in diabetic retinopathy is typically combined with Endo laser PRP. The visual outcome depends upon the severity of the preexisting condition.
  • Severe persistent vitreous hemorrhage
  • Progressive RD
  • Combined tractional and rhegmatogenous RD
  • Premacular retrohyloid hemorrhage
Warning signs of retinal detachment include:
  • blurry vision
  • darkened or dimmed vision
  • sudden and numerous floaters
  • flashing lights in the side of your vision

If you suspect a retinal detachment, it is important to seek medical attention immediately by calling emergency services or attending a nearby emergency department.

Which stage am I at?

If you had a diabetic eye screening test, you will be sent a letter saying that you have one of the following:

  • No retinopathy means no signs of retinopathy have been detected and you should attend your next screening appointment in 12 months.
  • Background retinopathy – If you have background retinopathy, this means you have stage 1 retinopathy and should schedule your next screening appointment in 12 months. If your diabetes is not well controlled, you may be seen sooner.
  • degrees of referable retinopathy – This means you have stage 2 or 3 retinopathy, or diabetic maculopathy, and should have more frequent tests or see a specialist about possible treatments.

When to see a doctor

If you have diabetes, make an appointment with an eye care specialist at least once a year. or more frequently as your doctor advises.

If your glucose level is still high despite taking medicine and other changes, you should also visit your doctor. or if you notice any changes in eyesight, even if they are subtle.

How to Protect Your Eyes When You Have Diabetes

Exercise Regularly

Working out is a trifecta: Moderate exercise raises HDL cholesterol — and lowers blood sugar and blood pressure. It has a direct positive effect on the eyes. Even brisk walking and cleaning the house count as physical activity. Most people should get at least 30 minutes on most days.

Eat Fish

Omega-3s in fatty fish such as salmon, halibut, mackerel, albacore tuna, and sardines have been linked to lower rates of diabetic retinopathy stages. Scientists believe that omega-3 fatty acids protect the eye against inflammation and abnormal blood vessel growth. Two servings should be taken a week.


Stress can also increase blood pressure and blood sugar levels. Experts say that meditation helps you solve stressful problems and let go of useless thoughts. Relax your mind and relax your body!

Drink More Water

Dehydration can increase blood sugar levels. But since sodas and juices can crash your glucose, it’s safer to sip on water. If you’re not a fan of plain, toss it with fruit or herbs (think strawberries and mint) for flavor without added sugar.

Sport Shades

The sun’s powerful UV rays can damage your eyes and increase your chances of eye problems, including cataracts. Since you can’t change the fact that you have diabetes, do something you can control. Even on cloudy days, wear sunglasses that block at least 99% of UVA and UV-B rays.

Pass The Greens, Please!

Dark, leafy greens such as kale, romaine lettuce, spinach, collard, and turnip greens are high in the nutrients lutein and zeaxanthin. These antioxidants help protect your retinal cells and, along with vitamin E, can help prevent cataracts. peas, Broccoli, eggs, and corn are also good sources.

Take Your Medication Correctly

For it to do its job, you have to follow the instructions. This includes when, how, and how much. If you take insulin, keep it at the right temperature, away from sunlight. Tell your doctor if your blood sugar is often too high or too low. Your diet, or the medicine you take, may need to be adjusted.

Favor Fiber

It slows down the release of glucose into your system. And foods high in soluble fiber can help lower your “bad” LDL cholesterol levels, too. Nutritionists recommend 20-30 grams of fiber per day. So, start your morning with oat-based cereal or oatmeal. Other good sources include barley, whole grains, lentils, beans and nuts, eggplant and okra, and pectin-rich fruits (such as grapes, apples, citrus, and strawberries).

No Cigarettes

Smoking is not only bad for your health but also for your eyes. For example, you are twice as likely to develop cataracts. And it tops your odds of having problems due to diabetes. Smokers are more likely to develop diabetic retinopathy and have it worsened more quickly.


Diabetic retinopathy is a leading cause of blindness in the industrialized world, however regular examination and timely treatment with laser can prevent vision loss. Patients at risk of developing diabetic retinopathy should take care of the causative factors, especially diabetic control.


  1. Can diabetic retinopathy affect only one eye

     Diabetic retinopathy usually affects both eyes.

  2. Can diabetic retinopathy go away?

    There is no cure But treatments work well to prevent delay or slow vision loss. The sooner the condition is detected, the easier it is to treat. And it is more likely that vision will be saved.

  3. What are three symptoms of diabetic retinopathy?

    ·         Spots or dark strings floating in your vision (floaters)
    ·         Blurred vision.
    ·         Fluctuating vision.
    ·         Dark or empty areas in your vision.
    ·         Vision loss.

  4. what is the first sign of diabetic retinopathy

    In the early diabetic retinopathy stages, there are usually no symptoms. Some people notice changes in their vision, such as difficulty reading or seeing distant objects. These changes may come and go.

  5. What is the first stage of diabetic retinopathy?

    The first stage is also called background retinopathy. This means that the tiny blood vessels in your retina have tiny bulges. Bulges are called microaneurysms. They can cause small amounts of blood to leak into your retina.

  6. How can you tell if diabetes is affecting your eyes?

    Your eyes may look fine, but the only way to know for sure is to have a thorough, comprehensive eye exam. Often, there are no warning signs of diabetic eye disease or vision loss when the damage first occurs.

Dr Sadia Ayaz
Dr Sadia Ayaz

I am an ophthalmologist and eye surgeon

Articles: 47

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