Vision Research xxx (2017) xxx–xxx

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Vision Research
journal homepage: www.elsevier.com/locate/visres

The pathology associated with diabetic retinopathy

Judith Lechner, Olivia E. O’Leary, Alan W. Stitt ⇑
Centre for Experimental Medicine, Queen’s University Belfast, Northern Ireland, UK

a r t i c l e i n f o a b s t r a c t

Article history: This review summarizes the pathological features of diabetic retinopathy. The lesions occurring in the
Received 14 March 2017 diabetic retina have been described over many decades using descriptive and experimental approaches
Received in revised form 4 April 2017 based on clinical studies on patients, human post-mortem material, animal models and various
Accepted 4 April 2017
in vitro systems. We have also accumulated a wealth of knowledge about basic molecular mechanisms
Available online xxxx
and key pathogenic processes that drive these abnormalities in diabetic retina. Despite these advances,
there are still limited therapeutic options for diabetic retinopathy with those currently available only
Keywords:
addressing late-stage disease. With a particular focus on the earlier stages of diabetes, there is growing
Diabetic retinopathy
Pathology
appreciation the complex neuronal, glial and microvascular abnormalities which progressively disrupt
Neurovascular unit retinal function. This is especially true from the perspective of the neurovascular unit during health
Microvascular and disease. Based on a strong appreciation of cellular and molecular pathology that underpins diabetic
retinopathy, further advances are anticipated as we drive towards development of efficacious therapeutic
options that can address all stages of disease.
Ó 2017 Elsevier Ltd. All rights reserved.

1. Basic retinal neuronal structure and its oxygenation 2. Maintenance of retinal homeostasis by the vasculature

The human retina consists of three layers of nerve cell bodies
interspaced by two plexiform layers of synapses. Rod and cone
photoreceptor cell bodies are located in the outer nuclear layer,
bipolar, horizontal and amacrine cells are found in the inner
nuclear layer and ganglion cell bodies and displaced amacrine cells
form the ganglion cell layer. Photoreceptor cells connect to second
order neurons, primarily bipolar and horizontal cells, and second
order neurons connect to ganglion cells in the inner plexiform
layer. Ganglion cell axons form the nerve fibre layer which trans-
ports the visual signal through the optic nerve to the visual cortex
in the brain. The retina has exceptionally high metabolic demands
with neural function being dependent on the constant availability
of oxygen and nutrients. Therefore, two vascular beds nourish the
retinal neuropile, each with distinct anatomy and function. Lying
beneath Bruch’s membrane, the choriocapillaris is a dense network
of highly fenestrated capillaries derived from the posterior ciliary
artery which oxygenates the outer retina. The intra-retinal vascu-
lature is an end-artery, multi-layered capillary network perfusing
the inner retina.
⇑ Corresponding author at: McCauley Chair of Experimental Ophthalmology,
Centre for Experimental Medicine, Queen’s University Belfast, 97 Lisburn Road,
Belfast BT9 7AE, Northern Ireland, UK.
E-mail address: a.stitt@qub.ac.uk (A.W. Stitt).
Retinal capillaries are the key interface for exchange of nutri-
ents, oxygen and metabolites between the neuropile and the circu-
lation. They are composed of non-fenestrated endothelial cells
surrounded by supporting pericytes and glial endfeet. Cell-cell
communication in the capillary unit is achieved via gap junctions
or through their shared basement membrane (BM). Together these
component cells regulate blood flow to compensate for changes in
retinal oxygenation and ocular perfusion pressure (Flammer &
Mozaffarieh, 2008). While the choriocapillaris is under the influ-
ence of autonomic innervation from sympathetic nerves, the
intra-retinal vasculature is autoregulated in response to metabolic
demands of the neurons (a phenomenon known as neurovascular
coupling) (Kur, Newman, & Chan-Ling, 2012). Autoregulation
ensures a constant retinal blood flow and ensures that delivery
of oxygen and nutrients matches the activity of defined regions
of the neural retina. For instance, light to dark transition as well
as light stimulation in certain areas of the retina results dynamic
changes to vessel diameter and blood flow (Kur et al., 2012).
Oxygen distribution varies across the retina and this corre-
sponds to the consumption rates of different cell-types. For exam-
ple, the photoreceptors have very high oxygen demands and thus
the highest levels of oxygenation occurs in the choroid (Caprara
& Grimm, 2012). Photoreceptors remain depolarised in the absence
of light and maintenance of the ‘‘dark current” requires the activity
of energy-consuming Na+-K+ ATPase pumps (de Gooyer et al.,

http://dx.doi.org/10.1016/j.visres.2017.04.003
0042-6989/Ó 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Lechner, J., et al. The pathology associated with diabetic retinopathy. Vision Research (2017), http://dx.doi.org/10.1016/j.
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2006). Under dark adaption conditions, increased aerobic metabo- Table 1

lism by photoreceptor inner segments may necessitate oxygen Classification of diabetic retinopathy based on observed clinical features (modified
from Das et al. (Das, Stroud, Mehta, & Rangasamy, 2015)).
supplied by the deep plexus of the retinal vasculature in order to
maintain homeostasis (Yu & Cringle, 2002). Disruption to this del- Classification Ophthalmoscopic features
icately balanced oxygen supply, as occurs in the case of retinal vas- No retinopathy No abnormalities
cular insufficiency, is a key factor in the development of many Mild NPDR Microaneurysms only
retinal pathologies, including diabetic retinopathy. Moderate NPDR Two or more of the following features:
Microaneurysms
Retinal vascular endothelial cells are linked by tight junctions Retinal hemorrhages
and adherens junctions and constitute an important component Hard exudates
of the highly selective inner blood retinal barrier (iBRB) Severe NPDR Any one of the following features:
(Antonetti, Lieth, Barber, & Gardner, 1999). The BRB is a highly 20 hemorrhages in each of the four quadrants
Venous beading in two quadrants
selective barrier that regulates molecular exchange between the
IRMAs in one quadrant
retina and circulation. This barrier is composed of inner and outer Very severe NPDR Any two of the above features
components, with the primary function to protect the retina from PDR One or both of the following features:
potentially toxic molecules in the circulation. The outer BRB (oBRB) Neovascularization
is formed from tight junctions between adjacent pigmented Vitreous hemorrhage

epithelial cells (RPE) (Cunha-Vaz, Faria, & Campos, 1975).

3. Brief overview of clinical aspects of diabetic retinopathy
Diabetic retinopathy remains a leading cause of sight-loss
among the working age population of industrialised regions. As
of 2010, this complication affected over 100 million patients
worldwide and is continuing to rise to expected >190 million by
2030 (Zheng, He, & Congdon, 2012). Diabetic macular edema
(DME) and proliferative diabetic retinopathy (PDR) are the major
sight-threatening endpoints of diabetes. In addition, diabetic
ischemic maculopathy describes retinal microvascular degenera-
tion within the macular region which can also result in loss of cen-
tral visual acuity. All of these endpoints are associated with poor
glycemic control and prolonged disease duration.
Diabetic retinopathy is largely asymptomatic in the early stages
and there is a need for regular eye screening for patients with dia-
betes to enable timely diagnosis and subsequent management of
the condition (Jones & Edwards, 2010). While initial diagnosis of
diabetic retinopathy may be based on functional changes in elec-
troretinography (ERG), retinal blood flow and retinal blood vessel
calibre (Nguyen et al., 2008), in practice the early clinical features
of this complication are evident in the fundus on ophthalmoscopic
examination (Fig. 1). Thus diabetic retinopathy is currently catego-
rized based on the presence of vascular (and closely associated)
lesions and on the absence or presence of neovascularization. There
are two general categories: (a) non-proliferative diabetic retinopa-
thy (NPDR) or (b) proliferative diabetic retinopathy (PDR) (Table 1).
Early clinical features of diabetic retinopathy include microa-
neurysms, dot and blot hemorrhages, cotton wool spots and intra-
retinal microvascular anomalies (IRMAs) (Fig. 1) (Lois, McCarter,
O’Neill, Medina, & Stitt, 2014). Microaneurysms and dot hemor-
rhages appear as small lesions on the fundus and represent the bal-
looning of capillaries where the vessel wall is compromised from
loss of supporting pericytes and/or glial attachment. Hemorrhages
and the leakage of fluid from microaneurysms results in localised
edema that, when reabsorbed, can leave behind hard lipoprotein
deposits (‘‘exudates”) in the retinal neuropile (Fig. 1). Blot hemor-
rhages arise from clusters of occluded capillaries and can frequently
occur in conjunction with cotton wool spots which are localised
neuronal infarctions caused by disturbed axoplasmic flow. IRMAs
appear as large calibre tortuous vessels in areas of ischaemia and
may represent attempted vascular remodelling (Stitt et al., 2011).
As the severity of diabetic retinopathy progresses, capillary
non-perfusion leads to retinal ischaemia, which, in turn, causes
upregulation of pro-angiogenic cytokines that drive pathological
intra-retinal and intravitreal neovascularization. Neovasculariza-
tion occurs at the interface between perfused and non-perfused
retina and is associated with poor prognosis for visual outcome.
These new vessels often grow on the surface of the retina and pen-
etrate the inner limiting membrane into the vitreous. These vessels
are typically fenestrated, brittle and leaky which can result in vit-
reous haemorrhage. Repeated vitreous haemorrhaging is associ-
ated with gliosis and fibrovascular scar formation. Contraction of
fibrous tissue can result in tractional retinal detachment and sud-
den loss of vision (Stitt et al., 2016).
4. Brief overview of the clinical features of diabetic macular
edema
During diabetes, retinal thickening is due to extracellular and
intracellular edema created by BRB breakdown, often occurring

Fig. 1. Clinical and histological perspective on diabetic retinopathy. A: Fundus photograph of the right eye of a patient with NPDR and central involvement clinically
significant macular edema. Exudates from the vasculature are observed around the foveal centre. B: Trypsin digest retinal specimen of a type-2 diabetic patient with NPDR
stained with PAS-haematoxylin (image courtesy of Dr Tom Gardiner, Queen’s University Belfast). A centrally placed radial artery is flanked above and below by retinal veins
and the intervening capillary beds. Numerous microaneurysms stain strongly with PAS and show a predominantly peri-arterial distribution (arrows).

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visres.2017.04.003
 J. Lechner et al. / Vision Research xxx (2017) xxx–xxx
in association with altered ion homeostasis in Müller cells. The
macula is particularly susceptible to fluid accumulation that can
lead to edematous pathology (Ford et al., 2013). DME is commonly
associated with later stages of diabetic retinopathy and is observed
and quantified using Optical Coherence Tomography (OCT) which
can be used to non-invasively monitor retinal thickness and pro-
gression of edema. DME is traditionally classified as either focal
edema, with leakage associated with discrete areas of microa-
neurysms and hard exudates, and diffuse edema, with leakage
originating from dilated capillaries and IRMAs.
5. The retinal neurovascular unit as a basis for understanding
diabetic retinopathy
With structural and functional comparability to vessels in the
brain, retinal blood vessels are complex multicellular units com-
prising endothelial cells, pericytes (at the capillary level), vascular
smooth muscle cells (arteriolar/arterial level), glia, neuronal pro-
cesses and closely associated immune cells. This neurovascular
unit responds dynamically to circulatory and neural cues to regu-
late oxygenation and nutrition of the neuropile through blood flow
regulation and integrity of the BRB (Klaassen, Van Noorden, &
Schlingemann, 2013). While they function as an integrated unit,
it is useful to itemise each component cell separately because dia-
betes has differing pathophysiological consequences.
5.1. Pericytes and endothelial cells
In addition to providing structural support to the vessel wall,
pericyte coverage regulates the expression of tight junction pro-
teins in the adjacent endothelial cells. Pericytes wrap around reti-
nal capillaries providing structural support as well as modulating
endothelial cell function. While pericytes are separated from
endothelial cells by the BM, they are in direct contact through
holes in this matrix to allow the formation of cell to cell junctions
(Klaassen et al., 2013; Kur et al., 2012).
5.2. Retinal glia and neurons
Retinal glia, including Müller cells and astrocytes, provide
metabolic support to neurons and they also play a critical role in
maintaining the iBRB (Bringmann et al., 2006). Glial processes sur-
round all the blood vessels in the retina and are integral to normal
retinal homeostasis (Bringmann & Wiedemann, 2012). For exam-
ple, Müller cells regulate glucose flux between the circulation
and retinal neurons and have a role in providing substrates for aer-
obic metabolism in neurons by gluconeogenesis (Newman &
Reichenbach, 1996).
5.3. Immune cells
Microglia are the resident innate immune cells of the retina and
are of myeloid origin (Ginhoux et al., 2010). In the developing
retina, microglia are involved in the pruning of neuronal and vas-
cular networks through the phagocytic removal of apoptotic cell
debris (Hume, Perry, & Gordon, 1983). In the adult retina, ramified
(‘‘resting”) microglia occur in the inner and outer plexiform layers
and they are an important source of neurotrophic factors that sup-
port neuronal survival. Resting microglia continuously monitor
their environment but when activated, they shift towards an
amoeboid morphology. Microglia become mobile and macrophagic
in response to trauma such as infection or ischaemia and will also
produce a wide range of pro-inflammatory cytokines (Langmann,
2007). Microglia and recycling perivascular macrophages are inti-
mately associated with homeostasis of the neurovascular unit in
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3
health. Likewise, their activation in disease scenarios can evoke
profound changes to the normal function of the retina.
6. Key pathologies associated with the neurovascular unit
While diabetic retinopathy has been commonly considered as a
disease of the microvasculature, there is robust evidence showing
that dysfunctional neurovascular crosstalk plays a critical role in
this complication (Moran et al., 2016).
6.1. Microvascular pathology
Early in diabetes, loss of vascular autoregulation can lead to
nutrient and oxygen deprivation of the inner retina (Alder, Su,
Yu, Cringle, & Yu, 1997; Bursell et al., 1996). While defective blood
flow is an early indicator of retinal dysfunction during diabetes, it
is not an established clinical read-out and patients may continue to
be classed as ‘‘retinopathy-free” until the appearance of lesions
such as exudates and microaneurysms. From this histopathological
perspective, there are many hallmarks of diabetic retinopathy. For
example, retinal vascular BM thickening occurs early in diabetes
and is related to hyperglycemia-mediated increases in the produc-
tion of extracellular matrix proteins fibronectin and collagen com-
bined with impaired degradation processes (Roy, Ha, Trudeau, &
Beglova, 2010). It is feasible that capillary vascular BM thickening
impairs cell-cell communication of the endothelium with other
components of the neurovascular unit and this may contribute to
the loss of function (Stitt et al., 2016) (Fig. 2).
Pericyte death and subsequent weakening of the capillary may
result in microaneurysms (Curtis, Gardiner, & Stitt, 2009). These
structures are among the first clinically recognisable signs of
retinopathy in patients and are often visible upstream of areas of
non-perfusion (Gardiner, Archer, Curtis, & Stitt, 2007). Some
post-mortem histological studies have revealed that microa-
neurysms appear on the arteriolar side of the circulation upstream
of denuded arterioles and in association with large areas of capil-
lary non-perfusion (Gardiner et al., 2007). While microaneurysms
can be perfused or sclerosed, sometimes they contain accumula-
tions of circulating leukocytes which indicates a possible involve-
ment of inflammation in their formation (Stitt, Gardiner, &
Archer, 1995).
Retinal capillaries become progressively non-perfused in the
diabetic retina as a direct result vasodegeneration. This is a cardi-
nal feature of diabetic retinopathy as observed in post-mortem
specimens but also in long-term diabetic animal models (Stitt
et al., 2016) (Fig. 2). On trypsin digest preparations, these acellular
capillaries appear as naked BM tubes where the endothelial cells
have disappeared secondary to pericyte death (Stitt et al., 2016).
This non-perfusion underpins ischemic pathology and hypoxia
which is a pre-requisite for the sight-threatening endpoints of dia-
betic retinopathy. In particular, neovascularization and excessive
vasopermeability in the retina are linked to upregulation of VEGF
as one of the most important peptide secretions driving end-
stage pathology. Increased growth factor and pro-inflammatory
cytokine secretion in the diabetic retina likely comes initially from
hypoxic Müller cells and, as disease progresses, activated microglia
and infiltrating macrophages probably become the principal source
of these factors. (Wang, Yadav, Leskova, & Harris, 2010).
6.2. Neuroglial pathology
The diabetic milieu is associated with glial cell dysfunction (glio-
sis) which is marked by glial fibrillary acidic protein (GFAP) overex-
pression in the Müller cell (Fig. 2). Normally, only retinal astrocytes
express GFAP although in diabetes there is an increased expression
4 J. Lechner et al. / Vision Research xxx (2017) xxx–xxx

Fig. 2. Capillary and glial changes during diabetic retinopathy. Transmission electron micrograph showing a typical normal retinal capillary (A) composed of an endothelial
cell (E) and pericyte (P) surrounded by BM (arrows). In a diabetic rat, the BM is thickened (arrows) (B). Acellular capillaries can be detected in diabetic rats using
immunofluorescent staining (green) (arrow, C) showing the persistence of the BM tube (Red, Collagen IV positive) but absence of Isolectin B4-positive endothelial cells (C). In
} ller cell activation can be detected
sections of non-diabetic rat retina, GFAP staining is limited to the astrocyte cells in the nerve fibre layer (E) however in diabetic animals Mu
as GFAP-positive across the whole inner retina (F). Red: GFAP, Blue: DAPI.

of this intermediate filament protein in Müller cells (Hammes,
Federoff, & Brownlee, 1995; Mizutani, Gerhardinger, & Lorenzi,
1998). Indeed, Müller cell dysfunction is a consistent feature of dia-
betic retinopathy in animal models and is critical to dysfunction of
the neurovascular unit. For example, the capillary - Müller cell
interface becomes disrupted during diabetes (Biedermann et al.,
2004) as exemplified by changes to the inwardly rectifying chan-
nels. In particular, the Kir4.1 channel in Müller cell end-feet at
the capillary interface is mislocalised in diabetic retina and this
contributes to impaired water regulation and disruption of the iBRB
(Pannicke et al., 2006). Dysregulation of Kir4.1 and aquaporins on
Müller cells have been widely reported in diabetic animal models
(Berner et al., 2012; Curtis et al., 2011; Vacca et al., 2014) which
may precede death of these glia which further exacerbates loss of
normal retinal neuronal and vascular integrity.
6.3. Neuronal pathology
Compromise of the neural retina during diabetes can be demon-
strated using electroretinography (ERG) and the most consistent
defect is reflected in the oscillatory potential implicit time (influ-
enced by the electrophysiological communication between the
amacrine cells and the bipolar cells with interactions from gan-
glion cells to amacrine cells) (Tzekov & Arden, 1999). These
changes are important signposts to neural dysfunction as the dis-
ease progresses (Bearse et al., 2006). The overall importance of
neuronal and glial dysfunction has led to a proposed ‘‘feed-
forward” hypothesis in which dysfunction in neural cells con-
tributes to breakdown of the BRB which, in turn, promotes an
inflammatory and oxidative environment that perpetuates vascu-
lar dysfunction (Antonetti et al., 2006).
Overt degeneration of retinal neurons during diabetes is a con-
cept that was first described in the 1960s in post-mortem patient
samples. By the late 1990s experimental evidence reinforced this
finding by demonstrating that depletion of some neuronal popula-
tions occured in diabetic rodent models, possibly even prior to
appearance of obvious microvascular lesions (Barber et al., 1998;
Reiter & Gardner, 2003). Histologically, apoptosis of the retinal
ganglion cells (RGCs) may be the initial losses observed in the
diabetic retina. This may account for the reduced thickness of the

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retinal nerve fibre layer that has been detected in diabetic patients
without retinopathy or with only background disease
(Araszkiewicz et al., 2012; van Dijk et al., 2012). As reinforcing evi-
dence, several rodent models of diabetes have demonstrated apop-
tosis of RGCs as early as 5 (rat) or 10 (mouse) weeks after the onset
of hyperglycaemia (Kusari, Zhou, Padillo, Clarke, & Gil, 2007). In the
db/db type-two diabetic (T2D) mouse model, RGC apoptosis and
ERG deficits (reduction in OP and b-wave amplitudes) have been
reported, concurrent with evidence of retinal glutamate excitotox-
icity (Bogdanov et al., 2014). A growing body of evidence indicates
that hyperglycaemia-induced downregulation of a number of
important neurotrophic factors such as NGF, PEDF, IRBP and
somatostatin may have a central role in contributing to, or indeed
initiate, neuronal apoptosis and capillary dropout, In-depth discus-
sion of this experimental evidence is beyond the scope of this
review and is provided elsewhere (Simo & Hernandez, 2015).

6.4. Immune cell activation and their role in pathology

Early in diabetic retinopathy, there is evidence of an intravascu-

lar immune response with enhanced leukocyte-endothelial inter-
actions leading to a so-called leukostasis phenomenon.
Leukostasis is the adherence of white blood cells to the endothelial
cells lining blood vessels. It is observed within weeks of the onset
of hyperglycaemia in rodent models (Joussen et al., 2004;
Miyamoto et al., 1999). This process is initiated by activation of
vascular endothelium and circulating myeloid cells such as neu-
trophils and monocytes which become trapped in narrow-
channel retinal capillaries leading to occlusion and non-perfusion
(Valle et al., 2013). Leukostasis occurs in short-term diabetic ani-
mal models (Joussen et al., 2004) but has also been demonstrated
in patients (Chibber, Ben-Mahmud, Chibber, & Kohner, 2007). The
link between capillary leukostasis and acellular capillary formation
in the retina has been demonstrated by studies with animals in
which the adhesion molecules (ICAM-1 and CD18) and/or immune
cell activators (iNOS) have been genetically deleted. These animals,
when rendered diabetic, are significantly protected from leukosta-
sis and capillary death (Joussen et al., 2004; Leal et al., 2007).
As inflammation increases in the diabetic retina it does so in a
self-propagating manner. Indeed, activation of microglial cells
and elaboration of pro-inflammatory cytokines are well-
described in human retina and animal models with a likely contri-
bution to retinal cell dysfunction and death (Zeng, Green, & Tso,
2008). Indeed there is a graduated and persistent inflammation
which occurs from the early stages of diabetes through to the
sight-threatening end-stages (as reviewed by (Tang & Kern,
2011). Chronic inflammatory conditions in the diabetic retina
result in the prolonged activation of microglia. Activated microglia
produce glutamate, iNOS and pro-inflammatory cytokines such as
IL-1b, IL-6, IL-12 and TNFa which can culminate in the activation
of caspases, exacerbating cell death in the retina (Krady et al.,
2005). Such cell activation responses are crucial to inflammation
in the diabetic retina as exemplified by experimental investiga-
tions in animal models and human post-mortem specimens
(Rungger-Brandle, Dosso, & Leuenberger, 2000; Zeng et al., 2008)
(Fig. 3).
6.5. RPE and choroid pathology in diabetic retinopathy
Although not part of the neurovascular unit, the RPE and under-
lying choroid are also affected by the diabetic milieu. For example,
RPE dysfunction and leakage from the choriocapillaris are associ-
ated with impaired fluid clearance and edema in the outer retina
(Simo, Villarroel, Corraliza, Hernandez, & Garcia-Ramirez, 2010).
Outer BRB (oBRB) compromise occurs in diabetes (Kowalczuk
et al., 2011; Runkle & Antonetti, 2011) and experimental systems
Fig. 3. Retinal microglia and morphology changes during diabetes. Resting retinal
microglia with long dendrites and small cell body (Ai and Aii). In diabetes, these
microglia have fewer and smaller cell processes and the cells are distributed
throughout the inner retina (Bi and Bii).
show that RPE dysfunction may be mediated through high glucose
(Beasley et al., 2014; Trudeau et al., 2011). Diabetic rats also show
oBRB compromise and this may result in photoreceptor apoptosis
and increased inflammation in the outer retina (Omri et al.,
2011). In addition, RPE-associated defects in the ERG have been
shown in T1D and T2D mouse models (Samuels, Bell, Pereira,
Saxon, & Peachey, 2015).
Choroidal atrophy has been observed in diabetic animal models
(Braun, Wienczewski, & Abbas, 2009; Hidayat & Fine, 1985; Muir,
Renteria, & Duong, 2012) and also in post-mortem diabetic eyes
(Lutty, 2013). Patients also demonstrate choroidal thinning (Cao,
McLeod, Merges, & Lutty, 1998; Esmaeelpour et al., 2012;
Fryczkowski, Hodes, & Walker, 1989; Hua, Liu, Wang, & Chen,
2013) which correlates with HbA1c levels (Unsal et al., 2014) and
occurrence of lesions such as vascular BM thickening, macro and
microaneurysms, intra-choroidal microvascular abnormalities
and choroidal neovascularization (Cao et al., 1998; Esmaeelpour
et al., 2012; Fryczkowski et al., 1989; Hua et al., 2013). While the
choroidal and retinal vascular beds are very different, it is interest-
ing to note that they may share some common pathological lesions
and there is merit in further understanding this outer retinal
pathology in the diabetic eye.
7. Pathogenic mechanisms leading to DR
Prolonged exposure to the diabetic milieu leads to the activa-
tion of a number of interconnecting biochemical pathways that
contribute to DR pathology. The key pathways involved in patho-
genesis of DR include increased glucose flux through the polyol
and hexosamine pathways, activation of protein kinase C (PKC),
overactivation of the plasma kallikrein-kinin (PKK) pathway and
accumulation of advanced glycation end products (AGEs) (Stitt
et al., 2016). Oxidative stress occurs as a result of
hyperglycaemia-induced mitochondrial overproduction of super-
oxide and has been postulated as the underlying stressor linking

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Fig. 4. Schematic overview of pathogenic mechanisms leading to the sight-threatening endpoints of DR. DR arises through a complex interplay between neuroglial and
vascular damage that results from hyperglycaemia-induced metabolic stress. From the microvascular perspective, hypoperfusion early in the disease due to loss of the cells
making up the endothelium ultimately leads to compensatory growth of new fragile and leaky blood vessels. Compromise of BRB integrity leads to the extravasation of fluid
and inflammatory mediators, creating sight threatening edema and exacerbating inflammatory conditions. Concurrent or preceding neuroglial dysfunction perpetuates
damage.

all of these pathways (Brownlee, 2005; Nishikawa et al., 2000). Acknowledgments

While the complexity of these pathogenic pathways is beyond
the scope of this article and are reviewed elsewhere (Antonetti,
Klein, & Gardner, 2012; Stitt, Lois, Medina, Adamson, & Curtis,
2013), it is relevant to contextualise these inter-connected pro-
cesses and their links to the pathologies outlined above (Fig. 4).
8. Conclusion
The complex pathology observed in the diabetic retina reflects
the inter-connected nature of all the component cells in this neural
tissue. An evolving body of evidence based on clinical pathology
and experimental data obtained over the last 20 years means that
there now exists an expanded view of diabetic retinopathy and
how it develops. While most current therapies remain focused on
late-stage PDR and DME, widening appreciation of the diabetes-
associated pathophysiology in the neurovascular unit should pro-
vide opportunities to prevent disease at a much earlier stage. It is
anticipated that in the coming years new pharmacological treat-
ments based on an understanding of the causative mechanisms
of diabetic retinopathy will be developed and address the need
for both vascular and neuroprotection.
The authors would like to acknowledge financial support from
Fight for Sight (UK), Diabetes UK, The Sir Jules Thorn Trust, DEL/
SFI; Wolfson Foundation and The Royal Society.
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