Grading Diabetic Eye Damage: Time for a New System?

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Thanks to recent studies, ophthalmologists now know more about the molecular, neural, vascular, and sys­temic processes that contribute to dia­betes-related retinal damage and disease progression. Yet the system for classify­ing and assessing these sight-threatening changes is lagging far behind, a group of researchers wrote in Ophthalmology.¹

Their proposed solution: A massive, coordinated, international effort to de­velop a new staging system that incor­porates these advances. “We think that, by updating the severity scales relevant to diabetic eye disease, we will be able to revise the current staging system to help us better predict outcomes in the diabetic eye. And in doing so, we can drive advances that are much needed in both research and clinical care,” said Jennifer K. Sun, MD, MPH, at the Joslin Diabetes Center’s Beetham Eye Institute in Boston.

LATE STAGE. Ring fibrosis in a patient with proliferative diabetic retinopathy. This image was originally published in the ASRS Retina Image Bank. Rudvij Pandya. Ring Fibrosis Proliferative Diabetic Retinopathy. Retina Image Bank. 2021; Image Number 72551. © The American Society of Retina Specialists.

Say hello to DRD. One semantic signal of this new focus comes from the terminology the group has adopted, said coauthor Michael D. Abràmoff, MD, PhD, at the University of Iowa in Iowa City. “We don’t say ‘diabetic retinopathy,’ because that just addresses the vascular component of the retinal damage in diabetic eyes.” Instead, the preferred phrase is now “diabetic retinal disease,” and the narrow acro­nym DR is being replaced by DRD, he said.

Developing the staging system. Six international panels are currently working on evidence-based recom­mendations for the met­rics to incorporate into an updated staging system for DRD. “Ideally, an updated staging system will address retinal, neural, and vascular pathology and their contri­butions to visual function in the context of systemic influences such as diabetes type, glycemic control, blood pressure, renal disease, and anemia,” Dr. Sun and her coauthors wrote.¹

“As we learn more about diabetes [and its neural components], we have found that neural damage happens early,” Dr. Abràmoff said. While he believes that neural damage occurs ear­lier than vascular damage does, some of his colleagues think that the neural and vascular damage are “kind of in­terrelated,” he added. “Everyone in the group has a different view, but we all realize that it’s more than just vascular damage, especially in the macula and the periphery.”

Role for AI. A new system might include disease assessments made with advanced retinal imaging tools, such as ultra-widefield photography, spectral-domain optical coherence tomography (OCT), and OCT angiography, said Dr. Sun, who also serves as chair of diabetes initiatives for the DRCR Retina Network.

Artificial intelligence (AI) tools might be needed to integrate all this complex information into a system that clinical ophthalmologists could easily use, she added. “So much automated decision support is possible with com­puterized algorithms. That’s one way to potentially make a system that—in and of itself—is quite complex and contains a lot of nuanced information but is easy to use clinically.”

Three years in the making. The roots of the project were laid down in 2018, during an international collo­quium cosponsored by the JDRF. That meeting led to the formation of this new initiative to re-envision DRD stag­ing, Dr. Sun said.

—Linda Roach

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1 Sun JK et al. Ophthalmology. Published online Nov. 17, 2020.

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Relevant financial disclosures—Dr. Sun: Adaptive Sensory Technology: S; Boston Micromachines: S; Genentech: C; Novartis: C; Novo Nordisk: C,S; Optovue: S; Roche: C,S. Dr. Abràmoff: Alimera: C; Digital Diagnostics: C,O,P; NovaGo: C.

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