Comprehensive Wellness Guide to Understanding and Managing Retinopathy

34% of diabetics have DR—7% vision-threatening. HbA1c <7% → 76% risk reduction. This 2025 expert-reviewed guide covers diabetic/hypertensive retinopathy, NPDR/PDR, OCT CST, FFA leakage, anti-VEGF (ranibizumab q4wk), PRP laser, fenofibrate, HbA1c/BP/lipid targets, and AI retinal screening. Includes annual exam protocol, injection schedule, and lifestyle.

Epidemiology and Risk Factors

• Diabetic Retinopathy (DR): 34% T2DM, 70% after 15 yrs
• PDR: 7% T2DM, 25% T1DM
• DME: 7–10% (macular edema)
• Hypertensive Retinopathy: 10% HTN, severe in 2%
• Risk: Duration DM, HbA1c >7%, HTN, dyslipidemia, pregnancy, nephropathy

Pathophysiology: Vascular Damage

Hyperglycemia → pericyte loss → microaneurysms → VEGF ↑ → neovascularization

• Early: Blood-retina barrier breakdown
• DME: Intraretinal fluid (CST >300 µm)
• PDR: Ischemia → VEGF → NV on disc/elsewhere
• Hypertensive: Arteriolar narrowing → AV nicking → flame hemorrhages

Diabetic Retinopathy Classification (ICDR)

Stage	Findings	Risk of PDR	Follow-up
No DR	—	—	Yearly
Mild NPDR	Microaneurysms only	Low	Yearly
Moderate NPDR	HE, CWS, VB	12%	6–12 mo
Severe NPDR	4:2:1 rule	50%	3–4 mo
PDR	NVD/NVE	High	Urgent

Hypertensive Retinopathy (Keith-Wagener-Barker)

Grade	Findings	Prognosis
I	Arteriolar narrowing	Mild
II	AV nicking	Moderate
III	Flame HE, CWS	Severe
IV	Papilledema	Malignant HTN

Diagnostic Workup

1. Dilated Fundus Exam (7-field stereo)
2. OCT: CST, intraretinal fluid, SRD
3. FFA: Ischemia, leakage, NV
4. OCTA: Non-invasive capillary dropout
5. Systemic: HbA1c, BP, lipids, renal function

Systemic Risk Factor Control

Parameter	Target	Evidence
HbA1c	<7.0%	UKPDS, DCCT
BP	<130/80 mmHg	ACCORD
LDL	<70 mg/dL	FIELD
Fenofibrate	160 mg/day	FIELD, ACCORD-Eye

Treatment: Diabetic Macular Edema (DME)

First-Line: Anti-VEGF

• Ranibizumab: 0.3 mg monthly × 5 → PRN (CST <250)
• Aflibercept: 2 mg q4wk × 5 → q8–12wk
• Bevacizumab: Off-label, cost-effective
• Response: 70–80% gain ≥10 letters

Second-Line: Steroids

• Dexamethasone implant (Ozurdex) q6mo
• Fluocinolone (Iluvien) 3 yrs

Focal/Grid Laser

• Adjunct if persistent edema

Treatment: Proliferative Diabetic Retinopathy (PDR)

Panretinal Photocoagulation (PRP)

• 1,200–1,600 spots, 300–500 µm
• 2–3 sessions
• Regression: 50% in 3 mo

Anti-VEGF for PDR

• Ranibizumab q4wk × 6 → PRP if stable
• Reduces vitrectomy risk 50%

Vitrectomy Indications

• Non-clearing VH >1 mo
• Tractional RD threatening macula
• Combined TRD + rhegmatogenous

Screening Protocol (ADA 2025)

Population	Start	Frequency
T1DM	5 yrs post-dx	Yearly
T2DM	At diagnosis	Yearly
Pregnancy	1st trimester	q3mo

Lifestyle and Supportive Care

• Glycemic: CGM, low-GI diet
• BP: DASH diet, exercise 150 min/wk
• Lipids: Omega-3, fenofibrate
• Smoking cessation: Doubles DR risk
• Low vision aids: Magnifiers, audio

Emerging Therapies (2025)

• AI Retinal Screening: 98% sensitivity (IDx-DR, EyeArt)
• Faricimab: Ang-2 + VEGF inhibitor
• Port Delivery System: Ranibizumab refill q6mo
• Gene Therapy: RGX-314 (anti-VEGF)

Red Flags: Urgent Ophthalmology

• Sudden vision loss
• Floaters + shadow (VH, RD)
• Distorted vision (DME)
• BP >180/110 (Grade IV)

Conclusion

Retinopathy is preventable, detectable, treatable. Screen yearly, control HbA1c/BP/lipids, treat with anti-VEGF/PRP. With AI screening and port delivery, 90% retain driving vision. One dilated exam, one injection, one lifetime of sight.