ДИАБЕТИЧЕСКАЯ РЕТИНОПАТИЯ: СОВРЕМЕННЫЕ ПОДХОДЫ К СКРИНИНГУ, ДИАГНОСТИКЕ И ПРОФИЛАКТИКЕ ПОТЕРИ ЗРЕНИЯ

УДК 617.735:616.379-008.64

Abstract

Background. Diabetic retinopathy is one of the leading microvascular complications of diabetes mellitus and remains an important cause of preventable visual impairment among adults. The aim of this review was to summarize current evidence on risk factors, screening, diagnosis and modern management of diabetic retinopathy.

Methods. A narrative review of scientific literature published mainly between 2017 and 2026 was conducted. The search was performed in PubMed, Scopus, Web of Science and Google Scholar using the keywords “diabetic retinopathy”, “diabetes mellitus”, “screening”, “optical coherence tomography”, “fundus photography”, “anti-VEGF therapy”, “diabetic macular edema” and “artificial intelligence”. Clinical guidelines, consensus documents, systematic reviews, narrative reviews and key clinical studies were included.

Result. Current evidence shows that diabetic retinopathy is associated with diabetes duration, poor glycemic control, arterial hypertension, dyslipidemia, nephropathy and pregnancy. Screening based on dilated fundus examination, retinal photography and optical coherence tomography allows early detection before irreversible visual impairment occurs. Anti-vascular endothelial growth factor therapy, laser photocoagulation and vitrectomy remain key treatment options depending on disease stage and the presence of diabetic macular edema.

Conclusion. Diabetic retinopathy requires timely screening, risk factor control and individualized ophthalmological management. Early diagnosis, interdisciplinary cooperation and regular follow-up may reduce the risk of severe visual complications and improve long-term outcomes in patients with diabetes mellitus.

Аннотация

Цель. Диабетическая ретинопатия является одним из ведущих микрососудистых осложнений сахарного диабета и остается важной причиной предотвратимого нарушения зрения среди взрослого населения. Целью настоящего обзора стало обобщение современных данных о факторах риска, скрининге, диагностике и современных подходах к ведению пациентов с диабетической ретинопатией.

Метод. Проведен нарративный обзор научной литературы, опубликованной преимущественно в период с 2017 по 2026 год. Поиск осуществлялся в базах данных PubMed, Scopus, Web of Science и Google Scholar с использованием ключевых слов: «диабетическая ретинопатия», «сахарный диабет», «скрининг», «оптическая когерентная томография», «фотография глазного дна», «анти-VEGF терапия», «диабетический макулярный отек» и «искусственный интеллект». В обзор были включены клинические рекомендации, консенсусные документы, систематические обзоры, нарративные обзоры и ключевые клинические исследования.

Результат. Современные данные свидетельствуют о том, что диабетическая ретинопатия ассоциирована с длительностью сахарного диабета, неудовлетворительным гликемическим контролем, артериальной гипертензией, дислипидемией, нефропатией и беременностью. Скрининг, основанный на осмотре глазного дна с расширением зрачка, ретинальной фотографии и оптической когерентной томографии, позволяет выявлять заболевание на ранних стадиях до развития необратимого нарушения зрения. Анти-VEGF терапия, лазерная фотокоагуляция и витрэктомия остаются основными методами лечения в зависимости от стадии заболевания и наличия диабетического макулярного отека.

Выводы. Диабетическая ретинопатия требует своевременного скрининга, контроля факторов риска и индивидуализированного офтальмологического ведения. Ранняя диагностика, междисциплинарное взаимодействие и регулярное наблюдение могут снизить риск тяжелых зрительных осложнений и улучшить долгосрочные исходы у пациентов с сахарным диабетом.

Keywords: diabetic retinopathy, diabetes mellitus, screening, diabetic macular edema, optical coherence tomography, anti-VEGF therapy.

Ключевые слова: диабетическая ретинопатия, сахарный диабет, скрининг, диабетический макулярный отек, оптическая когерентная томография, анти-VEGF терапия.

Introduction

Diabetic retinopathy is a chronic microvascular complication of diabetes mellitus and one of the major causes of preventable visual impairment in the working-age population. The disease develops as a result of long-term metabolic and vascular damage to the retinal microcirculation. Persistent hyperglycemia contributes to endothelial dysfunction, capillary basement membrane thickening, pericyte loss, vascular leakage, retinal ischemia and pathological neovascularization [1, 7, 8].

The clinical importance of diabetic retinopathy is determined by its initially asymptomatic course. In early stages, patients may not report any visual complaints, while retinal microvascular changes are already present. Visual symptoms usually appear when diabetic macular edema, vitreous hemorrhage, tractional retinal detachment or advanced proliferative diabetic retinopathy develops [2, 3]. Therefore, regular ophthalmological screening is essential for timely detection and prevention of irreversible vision loss [4].

The burden of diabetic retinopathy is increasing together with the global rise in diabetes mellitus. Epidemiological studies show that diabetic retinopathy is common worldwide and that its frequency is strongly influenced by diabetes duration, glycemic control and systemic vascular risk factors [5, 6]. Modern ophthalmology emphasizes that diabetic retinopathy should not be considered only an eye disease, but rather a manifestation of systemic vascular damage requiring cooperation between ophthalmologists, endocrinologists, primary care physicians and patients [1, 3].

Aim of the Review

The aim of this narrative review was to summarize current evidence on diabetic retinopathy, including risk factors, pathogenesis, screening methods, diagnostic approaches and modern strategies for prevention of vision loss.

Materials and Methods

A narrative review of scientific literature published mainly between 2017 and 2026 was conducted. The search was performed in PubMed, Scopus, Web of Science and Google Scholar. The following keywords and their combinations were used: “diabetic retinopathy”, “diabetes mellitus”, “diabetic macular edema”, “screening”, “fundus photography”, “optical coherence tomography”, “anti-VEGF therapy”, “laser photocoagulation”, “vitrectomy” and “artificial intelligence”. Clinical guidelines, consensus documents, systematic reviews, narrative reviews and key clinical studies addressing screening, diagnosis and treatment of diabetic retinopathy were included [1–4].

Risk Factors and Pathogenesis

The development and progression of diabetic retinopathy are strongly associated with the duration of diabetes and the quality of glycemic control. Long-standing diabetes and poor glycemic control increase the risk of retinal microvascular damage, while intensive glucose control reduces the probability of development and progression of microvascular complications [10, 11]. Additional risk factors include arterial hypertension, dyslipidemia, diabetic nephropathy, pregnancy, obesity and smoking [1, 2, 12].

The pathogenesis of diabetic retinopathy is complex and involves oxidative stress, inflammation, formation of advanced glycation end products, endothelial dysfunction and breakdown of the blood-retinal barrier. These mechanisms damage retinal capillaries and lead to vascular leakage, capillary non-perfusion and retinal ischemia [8, 9]. In response to ischemia, vascular endothelial growth factor increases, contributing to neovascularization and increased vascular permeability [7, 8].

Diabetic macular edema is one of the most important causes of visual impairment in patients with diabetic retinopathy. It develops due to breakdown of the blood-retinal barrier and accumulation of fluid in the macular region. Diabetic macular edema may occur at different stages of diabetic retinopathy and requires timely detection using optical coherence tomography [1, 3].

Classification and Clinical Manifestations

Diabetic retinopathy is commonly classified into non-proliferative and proliferative forms. Non-proliferative diabetic retinopathy may be mild, moderate or severe and is characterized by microaneurysms, retinal hemorrhages, hard exudates, cotton wool spots and venous abnormalities. Proliferative diabetic retinopathy is characterized by pathological neovascularization, which increases the risk of vitreous hemorrhage and tractional retinal detachment [3, 4].

In early stages, diabetic retinopathy is often asymptomatic. As the disease progresses, patients may develop blurred vision, fluctuating vision, dark spots, image distortion or sudden vision loss. The presence of symptoms usually indicates advanced disease or macular involvement. This underlines the importance of screening before visual complaints appear [2, 4].

Screening and Diagnosis

Screening is a central component of diabetic retinopathy prevention. Patients with diabetes should undergo regular ophthalmological examination according to diabetes type, disease duration, pregnancy status and previous retinal findings [2, 4]. Screening may include dilated fundus examination, color fundus photography and retinal imaging technologies. The American Academy of Ophthalmology notes that dilated fundus examination remains the gold standard for screening, while validated digital imaging can also be an effective detection method [3].

Optical coherence tomography is essential for detecting and monitoring diabetic macular edema. It provides quantitative and qualitative assessment of retinal thickness, intraretinal fluid, subretinal fluid and structural changes in the macula. OCT is particularly important when visual symptoms are present or when macular involvement is suspected [1, 3].

Fluorescein angiography may be used to evaluate retinal ischemia, vascular leakage and neovascularization. In addition, wide-field retinal imaging and modern imaging approaches can improve detection of peripheral retinal lesions and identify patients at higher risk of progression [3, 17].

Artificial intelligence has become an important emerging tool in diabetic retinopathy screening. Deep learning systems can analyze retinal fundus photographs and identify referable diabetic retinopathy with high diagnostic performance [18, 19]. AI-based screening may improve coverage in areas with limited access to ophthalmologists, but implementation requires validation, quality control, integration into clinical workflows and clear referral pathways [18, 19].

Treatment Principles

Management of diabetic retinopathy includes systemic risk factor control and ophthalmological treatment. Optimization of glycemic control, blood pressure and lipid profile remains fundamental for reducing disease progression [2, 11, 12]. Patient education and adherence to follow-up are equally important, because treatment effectiveness depends on regular monitoring [1, 3].

Anti-vascular endothelial growth factor therapy is currently a key treatment for center-involving diabetic macular edema and some cases of proliferative diabetic retinopathy. Intravitreal anti-VEGF injections reduce vascular leakage, improve macular anatomy and may improve visual acuity [15, 16]. However, treatment usually requires repeated injections and close follow-up [1].

Laser photocoagulation remains an important treatment option, especially in proliferative diabetic retinopathy. Panretinal photocoagulation reduces the risk of severe vision loss by decreasing ischemic drive and promoting regression of neovascularization [13, 14]. Focal or grid laser treatment may be considered in selected cases of diabetic macular edema, although anti-VEGF therapy has become the dominant approach for center-involving disease [13, 15].

Vitrectomy is indicated in advanced complications such as non-clearing vitreous hemorrhage, tractional retinal detachment involving or threatening the macula, and severe fibrovascular proliferation. Surgical treatment may preserve or restore vision in selected patients, but prevention, timely screening and early intervention remain preferable [3].

Prevention and Interdisciplinary Care

Prevention of vision loss from diabetic retinopathy requires a coordinated approach. Ophthalmologists should provide timely retinal assessment and treatment, while endocrinologists and primary care physicians should support systemic risk factor control. Patients should be informed that the absence of visual symptoms does not exclude diabetic retinopathy [2, 4].

Regular screening, adherence to diabetes treatment, blood pressure control, lipid management and smoking cessation are important preventive measures [1, 2, 12]. Pregnant women with diabetes require special attention because pregnancy may accelerate progression of diabetic retinopathy [2].

Teleophthalmology and AI-assisted screening may expand access to retinal evaluation, especially in primary care and remote regions. These technologies can improve early detection, but they should complement rather than replace specialist assessment in patients with referable or sight-threatening disease [18, 19].

Conclusion

Diabetic retinopathy is a common and potentially vision-threatening complication of diabetes mellitus. Its early stages may be asymptomatic, making regular screening essential for prevention of irreversible visual impairment [1, 2, 4]. Modern diagnosis is based on dilated fundus examination, retinal photography, optical coherence tomography and, when necessary, angiographic assessment [3, 17].

Effective management requires systemic risk factor control, timely ophthalmological treatment and long-term follow-up. Anti-VEGF therapy, laser photocoagulation and vitrectomy remain key treatment options depending on disease stage and complications [1, 13, 15]. Interdisciplinary cooperation, patient education and modern screening technologies are crucial for reducing the burden of diabetic retinopathy and preserving vision in patients with diabetes mellitus [18, 19].

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