Stages of Diabetic Retinopathy: What to Expect

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Diabetic retinopathy is a progressive eye disease that can lead to vision loss. It is a complication of diabetes. Diabetic retinopathy affects the blood vessels of the light-sensitive retinal tissue of the eye. This condition may or may not have signs. It depends on which of the four stages of the disease you are in.

This article will highlight the symptoms that occur at each of the stages, from mild nonproliferative diabetic retinopathy to proliferative diabetic retinopathy, It will also discuss what your options are at each stage.

Person getting an eye examination to track diabetic retinopathy

AzmanJaka / Getty Images

Stage 1: Mild Nonproliferative Diabetic Retinopathy

In this early stage of diabetic retinopathy, also known as background retinopathy, there are not yet any symptoms. But when an eye doctor examines you, some tiny microaneurysms (bulges in blood vessels) may be present. What an eye specialist may notice are extremely small bulges in blood vessels that may leak ever so slightly.

Symptoms

Even though your ophthalmologist (a physician who treats eye conditions) may be able to see signs in your eyes, your vision remains completely unaffected. In short, you will likely have no symptoms that you can detect.

What to Do

The American Diabetes Association (ADA) recommends that people with diabetes be referred to an ophthalmologist for their follow-up. At this stage, there is really nothing to do regarding treatment, apart from making sure you get yearly eye checkups to see if there have been any changes.

Even though your vision has not yet been affected, seeing signs such as leaking blood vessels puts you at increased risk of progressing to the next stage. This is particularly true if such signs appear in both eyes.

However, during this stage, you can try to head off progression by working on managing your blood sugar levels and improving your overall health. Some lifestyle steps you can take here include:

  • Watch your diet: This will ensure that your blood sugar is controlled and that salt and fat levels in your diet are healthy.
  • Monitor blood sugar levels: Your hemoglobin A1c (a blood test that monitors blood sugar control over the past few weeks) should be around 6.5%.
  • Get reasonable exercise: Strive to do about 2.5 hours of exercise each week, such as walking or cycling.
  • Lose weight, if needed: Your body mass index (BMI) should be in the 18.5 to 24.9 range.
  • Quit smoking.
  • Drink only in moderation.

About BMI

Body mass index (BMI) is a dated, biased measurement that doesn’t account for several factors, such as body composition, ethnicity, race, gender, and age. Despite being a flawed measure, BMI is widely used today in the medical community because it is an inexpensive and quick method for analyzing potential health status and outcomes.

Stage 2: Moderate Nonproliferative Diabetic Retinopathy

At the moderate stage, also dubbed pre-proliferative retinopathy, there's an increase in microaneurysms, as well as what's known as dot blot hemorrhages that are shaped like bullet points.

What's going on is some of the blood vessels are being damaged by high blood sugar levels. The damage can result in their becoming blocked, swelling, and leaking. They may, in turn, not be able to nourish the retina as they should.

The ophthalmologist may also detect what's known as cotton wool spots. These fluffy white cloud-like patches are thought to occur when the retina is not getting enough blood. The cotton wool spots will eventually disappear on their own.

Symptoms

At this stage, mainly just an ophthalmologist will notice changes in your eyes. Some vision changes may begin to occur (although they are more common later), such as blurring. These should be brought to your ophthalmologist's attention.

What to Do

You should continue to undergo frequent monitoring every six to nine months. Even if your vision is not yet affected, the concern is that it will be soon. The earlier your ophthalmologist can detect changes and be prepared to intervene, the better.

Stage 3: Severe Nonproliferative Diabetic Retinopathy

At this stage, your eye has hemorrhages within the retina in all four quadrants, as even more blood vessels become blocked. With not enough blood going to the retina, the body in turn may signal for the growth of new blood vessels.

Unfortunately, there is a high likelihood that you will develop the progressive stage of diabetic retinopathy within one year.

Symptoms

You may experience some blurring from time to time due to swelling of the retina, a condition known as diabetic macular edema. Such diabetic macular edema occurs in about half of those with diabetic retinopathy and can ultimately lead to vision loss.

Some of the blood vessels in the retina may also begin to shut down, limiting blood supply to the area. This can result in what's known as macular ischemia and can also cause blurry vision.

What to Do

During this period, you will likely be referred to a retinal specialist and be monitored as frequently as every three to six months.

If you are beginning to experience blurring or visual distortion, laser treatment may be helpful for macular edema caused by leaking blood vessels. Laser energy can be used to seal damaged leaking blood vessels keeping the retina from swelling.

But many retina specialists today will treat such clinically significant macular edema with the injection of anti-vascular endothelial growth factor (anti-VEGF) medications and corticosteroids.

Stage 4: Proliferative Diabetic Retinopathy

In the proliferative stage, abnormal new blood vessels begin to form. Leakage of the blood vessels onto the retina can cause scarring. This scarring can tug on the retina and cause it to pull away from the back of the eye (retinal detachment) and threaten vision.

Symptoms

If the blood vessels begin to substantially leak into the vitreous (the jelly-like substance within the eye), you may see dark spots or cobweb-like streaks from time to time.

While these may disappear on their own, it's important to immediately contact your ophthalmologist or retinal specialist and go for treatment. Otherwise, this can cause scarring and potentially lead to a retinal detachment.

Potential symptoms of a retinal detachment include:

  • Light flashing in one or both eyes
  • A lot of squiggly lines or shapes that drift across your visual field (known as floaters)
  • What seems to be a curtain drawn in part of your visual field

What to Do

If you see these symptoms, this is potentially an emergency. You need to seek help right away to avoid permanent vision loss. Likewise, if you notice any visual blurring or distortion, or see cobwebs in your line of sight even temporarily, reach out to your ophthalmic specialist right away.

This will enable them to treat your diabetic retinopathy as early as possible and potentially preserve your vision. Once you are in the proliferative diabetic retinopathy stage, you should be monitored every three months.

Summary

Diabetic retinopathy is a complication of diabetes involving the blood vessels of the retina. If you have diabetic retinopathy, you may be in one of four different stages.

These include three stages of non-proliferative retinopathy, in which there can be progressive leakage from the blood vessels already present, and your vision may or may not be affected.

With stage 4 proliferative retinopathy, leaky new blood vessels begin to form and can lead to scarring on the retina, which has the potential to cause a retinal detachment.

A Word From Verywell

If you have diabetes, you are likely being monitored for diabetic retinopathy. Knowing that this progresses through stages and takes time can be helpful.

If there were no signs of progression at your last appointment, you can feel confident that even if you have begun to develop symptoms, it's likely still early in the course of the disease. Actions can be taken to help preserve your sight at every stage.

Frequently Asked Questions

  • Do you go blind from diabetic retinopathy?

    It is possible to lose your vision from diabetic retinopathy without proper monitoring and treatment. Fortunately, anti-VEGF injections and laser treatment can help preserve your vision.

  • Can diabetic retinopathy improve?

    Treatment can slow the course of this disease and can even reverse aspects of it. For example, anti-VEGF injections can reverse the formation of new blood vessels, which can be a big factor in slowing the progression of diabetic retinopathy.

  • How quickly does diabetic retinopathy get worse?

    That depends on individual factors such as the severity of your diabetes. But if diabetic retinopathy is well monitored and steps are taken along the way, such as lowering blood sugar levels and undergoing prompt treatment, you can slow the progression and may even be able to keep vision issues from arising.

13 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. National Health Services. Stages diabetic retinopathy.

  3. National Health Services. Diabetic retinopathy prevention.

  4. American Academy of Ophthalmology. Diabetic retinopathy.

  5. American Academy of Ophthalmology. Diabetic retinopathy pathophysiology.

  6. University of Iowa Healthcare. Diabetic retinopathy: from one medical student to another.

  7. Centers for Disease Control and Prevention. Diabetes and vision loss.

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By Maxine Lipner
Maxine Lipner is a long-time health and medical writer with over 30 years of experience covering ophthalmology, oncology, and general health and wellness.