Cunha-Vaz José, Mendes Luís, Reste-Ferreira Débora
AIBILI - Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal.
Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
Eye (Lond). 2025 Jul 11. doi: 10.1038/s41433-025-03901-3.
It is well accepted that only a subset of individuals with diabetes is expected to progress to advanced retinopathy and is at risk of losing functional vision. It is, therefore, of major relevance to identify this subset of patients and when they enter into rapid progression. The Early Treatment Diabetic Retinopathy Study (ETDRS) severity scale is the classic gold standard for grading diabetic retinopathy progression. The fundus abnormalities seen in Diabetic Retinopathy can conceptually be split into three main phenotypes. Those resulting from retinal neurodegeneration, those related to an alteration of the Blood-Retinal Barrier and, finally, those resulting from ischemia. In eyes showing the ischemic phenotype, disease progression is characterized by an initial stage of increasing hypoperfusion involving initially the superficial capillary plexus with progressive involvement of the deep capillary plexus followed by an hyperperfusion response consisting of dilated shunt vessels and intraretinal microvascular abnormalities. Visual acuity is generally maintained as the retinopathy progresses to loss of visual acuity as a result of either clinically significant macular oedema (CSMO) or proliferative diabetic retinopathy (PDR). It is the microvascular changes that occur in response to the progressive capillary closure and the hyperperfusion response characterized by abnormally dilated shunt vessels that create the conditions for CSMO and PDR. Our present understanding of the progress of diabetic retinal disease indicates that prevention of the major vision-threatening complications, may be addressed by either halting the progressive ischemia which characterises the initial hypoperfusion stage or by targeting the angiogenic and inflammatory response that follows.
人们普遍认为，只有一部分糖尿病患者会发展为晚期视网膜病变并有丧失功能性视力的风险。因此，识别出这部分患者以及他们何时进入快速进展期具有重大意义。早期糖尿病性视网膜病变研究（ETDRS）严重程度量表是分级糖尿病性视网膜病变进展的经典金标准。糖尿病性视网膜病变中所见的眼底异常在概念上可分为三种主要表型。那些由视网膜神经变性引起的，那些与血视网膜屏障改变有关的，以及最后那些由缺血引起的。在表现为缺血表型的眼睛中，疾病进展的特征是最初阶段灌注不足增加，最初累及浅层毛细血管丛，随后逐渐累及深层毛细血管丛，接着是由扩张的分流血管和视网膜内微血管异常组成的高灌注反应。随着视网膜病变进展到因临床显著性黄斑水肿（CSMO）或增殖性糖尿病性视网膜病变（PDR）导致视力丧失，视力通常会保持。正是由于渐进性毛细血管闭塞以及以异常扩张的分流血管为特征的高灌注反应所引发的微血管变化，为CSMO和PDR创造了条件。我们目前对糖尿病视网膜疾病进展的理解表明，预防主要的视力威胁性并发症，可以通过阻止表征初始灌注不足阶段的渐进性缺血，或者通过针对随后的血管生成和炎症反应来实现。
