The unmet need for better risk stratification of non‐proliferative diabetic retinopathy

Diabetic retinopathy is a common microvascular complication of diabetes and remains one of the leading causes of preventable blindness in working‐age people. Non‐proliferative diabetic retinopathy is the earliest stage of diabetic retinopathy and is typically asymptomatic. Currently, the severity of diabetic retinopathy is assessed using semi‐quantitative grading systems based on the presence or absence of retinal lesions. These methods are well validated, but do not predict those at high risk of rapid progression to sight‐threatening diabetic retinopathy; therefore, new approaches for identifying these people are a current unmet need. We evaluated published data reporting the lesion characteristics associated with different progression profiles in people with non‐proliferative diabetic retinopathy. Based on these findings, we propose that additional assessments of features of non‐proliferative diabetic retinopathy lesions may help to stratify people based on the likelihood of rapid progression. In addition to the current classification, the following measurements should be considered: the shape and size of lesions; whether lesions are angiogenic in origin; the location of lesions, including predominantly peripheral lesions; and lesion turnover and dynamics. For lesions commonly seen in hypertensive retinopathy, a detailed assessment of potential concomitant diseases is also recommended. We believe that natural history studies of these changes will help characterize these non‐proliferative diabetic retinopathy progression profiles and advance our understanding of the pathogenesis of diabetic retinopathy in order to individualize management of people with diabetic retinopathy.