The Four Stages Of Diabetic Retinopathy

Up close photo of the eye.

Diabetes is a significant public health concern in the United States. As the number of people living with diabetes increases, it’s critical to make diabetes healthcare more accessible. Increasing access to diabetic retinopathy screenings can reduce the risk of vision loss or blindness. 

Diabetes Infographic

Source: Centers for Disease Control (

According to the American Academy of Ophthalmology, diabetic retinopathy is an eye disease that occurs when high blood sugar levels cause damage to blood vessels in the retina. The affected blood vessels can sometimes swell and leak, or they can close altogether, which causes a blockage and prevents blood from passing through.

Nearly all patients with diabetes will eventually develop diabetic retinopathy. The condition is detectable with a non-invasive screening. Early detection of mild diabetic retinopathy or moderate diabetic retinopathy makes treatment more effective, reducing the risk of vision loss.

Who is At Risk for Diabetic Retinopathy?

Anyone with diabetes, whether it’s type 1, type 2, or gestational, can develop diabetic retinopathy. It is more likely, the longer a person has diabetes. 

Researchers have found that nonproliferative diabetic retinopathy (NPDR) was present in 25% of patients five years after they were diagnosed with diabetes, 60% at 10 years, and 80% at 15 years. These studies also found that the incidence of proliferative diabetic retinopathy (PDR) varied from 2% in those who had diabetes for less than 5 years to 15.5% in those who had diabetes for 15 or more years. 

Over the long term, even patients with well-controlled blood sugar levels are likely to develop diabetic retinopathy. Regular screening with retinal imaging detects changes associated with early retinopathy stages, allowing for more effective treatment options.

The Four Stages of Diabetic Retinopathy

The four stages of diabetic retinopathy are classified as mild, moderate, severe (nonproliferative), and proliferative. 

Baseline – No Diabetic Retinopathy is found: Non-proliferative diabetic retinopathy (NPDR)

normal fundus

Normal Fundus

1. Mild NPDR



The first of the diabetic retinopathy stages is characterized by a balloon-like swelling in certain areas of the blood vessels in the retina called microaneurysms. This stage rarely affects vision or needs treatment, but it does signal diabetes damage has occurred and an increased risk of disease progression.

When minimal diabetic retinopathy is detected, providers can offer patient education on blood sugar management and reducing risks of complications from diabetes. In addition, providers should encourage patients to get diabetic retinopathy screenings every 6 months to monitor their eye health. 

2. Moderate NPDR

Moderate NPDR

Moderate NPDR

The next diabetic retinopathy stage is characterized by damage to some of the blood vessels in the retina, resulting in leakage of blood and fluid into the retina tissue. This fluid can cause a loss of vision. 

When moderate diabetic retinopathy is detected, providers may refer patients to appropriate specialists, such as ophthalmology or endocrinology, as needed. Providers should work with patients to adjust their diet and blood sugar control regimens to slow the progress of the disease. Patients should continue to have retinal screenings to monitor eye health.

3. Severe NPDR

Severe NPDR

Severe NPDR

If there is continued inadequate control of diabetes, more blood vessels are damaged and blocked with even more leakage of blood and fluid into the retina, resulting in a much greater impact on vision. 

In cases of severe nonproliferative diabetic retinopathy, a timely referral to a retinal specialist is recommended. The patients should be monitored every 3 to 4 months and work with an endocrinologist or primary care provider on diabetes management. 

4. Proliferative Diabetic Retinopathy

Proliferative Diabetic Retinopathy

Proliferative Diabetic Retinopathy

The most severe stage of Diabetic Retinopathy is Proliferative Diabetic Retinopathy. There is extensive damage to the eye’s blood vessels and worsening circulation inside the eye. In response, the retina grows new blood vessels, but they tend to have abnormal formation and can cause severe damage.

At this point, the disease has advanced significantly and can result in vision loss or blindness very threatening to one’s vision. 

Patients with proliferative diabetic retinopathy require immediate referral to a retina specialist for further examination and treatment. The patient may require injections of anti-VEGF drugs to stop the formation of new blood vessels. Laser treatments can be used to shrink abnormal vessels and reduce leaking. In some cases, a surgical vitrectomy to remove abnormal vessels and scarring may be appropriate. 

Costs of Diabetic Retinopathy Treatments

The costs of managing severe diabetic retinopathy are significant. The per-dose cost of anti-VEGF drugs can range from $1,850 to $3,200. Vitrectomy surgery costs about $7,000, while laser treatments cost around $2,000.
In contrast, regular screening to detect and manage diabetic retinopathy in the early stages can save thousands of dollars in future care and optimize vision preservation.

Ensuring Early Detection of Diabetic Retinopathy

The American Diabetes Association recommends annual diabetic retinal evaluations. These crucial retinal evaluations can detect damage prior to any perceived deterioration in a patient’s vision while also providing the opportunity to develop a treatment plan of action. This action plan can then provide a guideline for both patients and providers, ensuring a holistic understanding and treatment of how a patient’s diabetes is affecting their overall health. 

Solutions such as IRIS offer a wide range of healthcare providers the means to conduct these critical screenings. This allows patients to access care without needing to make a separate ophthalmology appointment. 

Optometrist utilizing IRIS screening software on patient

IRIS’s solution helps providers and patients stay ahead of the curve in treating and preventing further development to advanced stages of diabetic retinopathy.

The IRIS solution is simple to use and can be integrated with nearly any EMR system. After the image is taken using a retinal camera, it is sent electronically to the IRIS Reading Center, where licensed and experienced eye care professionals can accurately grade the images, and the diagnoses are quickly sent straight back to a provider’s EMR. With this convenient, quick, and non-invasive eye exam, providers can help close care gaps and give their patients effective and actionable care plans.

The IRIS solution makes it easy for healthcare practices to provide annual diabetic retinopathy screenings. The system uses proprietary software that enhances fundus imagery, allowing interpreting providers to identify and diagnose pathology easily. The IRIS solution integrates with nearly any retinal camera and existing EMR workflow to make the implementation of the software as seamless as possible.

IRIS offers comprehensive onsite or virtual training for all staff in non-eyecare settings to make it easy to get up and running. 

The IRIS Solution for In-Home Evaluations

The IRIS solution also works with portable retinal camera systems, making it ideal for in-home evaluation providers looking to improve their preventive screening measures. The IRIS solution helps in-home healthcare providers meet diabetic patients where they are in their health journey, and close gaps in patient care more effectively and efficiently. 

Optometrist using portable retinal camera on patient

The IRIS solution is one of the best ways insurance payors and other organizations who leverage health risk assessments (HRAs) can offer a preventative screening exam for diabetic retinopathy as a part of their in-home screening procedures. Improved quality of care, especially in the home setting, can lead to lower overall costs and a positive change in HEDIS/Star compliance.

Reach out today to see how IRIS can improve your patient care.


Frequently Asked Questions

How long does it take for diabetic retinopathy to progress?

Most people begin to develop diabetic retinopathy within 5 to 15 years of developing diabetes. Progression depends on individual health and how well blood sugar is managed. 

What do people see when they have diabetic retinopathy?

There may not be any vision changes in the early stages of diabetic retinopathy. As the condition progresses, patients may notice dark, floating spots or streaks across their field of vision, dark or empty patches, blurred vision, or loss of vision.

How does diabetic retinopathy affect the body?

Diabetic retinopathy damages the blood vessels in the eye, causing them to swell and leak. It can also lead to scarring or abnormal blood vessel formation in the eye. Complications include diabetic macular edema (DME), retinal detachment, and neovascular glaucoma.

How does diabetic retinopathy get worse?

High blood sugar levels can lead to the blockage of the tiny blood vessels in the eye. Over time, the damage increases and causes more vision problems. 

How do you know if you have diabetic retinopathy?

Diabetic retinopathy is diagnosed using screening tests such as retinal imaging, dilated eye exam, and fluorescein angiography. It can’t be confirmed by symptoms alone.




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