s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/survophthal

Major review

Early detection of diabetic retinopathy

Hamid Safi, MD, MPHa, Sare Safi, PhDb, Ali Hafezi-Moghadam, MD, PhDc,
Hamid Ahmadieh, MDa,*
a
Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b
Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
c
Molecular Biomarkers Nano-Imaging Laboratory, Brigham and Women’s Hospital, Department of Radiology,
Harvard Medical School, Boston, Massachusetts, USA

article info abstract

Article history: Diabetic retinopathy (DR) is a primary cause of visual impairment worldwide. Diabetes
Received 2 December 2017 mellitus may be associated with ophthalmoscopically nonvisible neurovascular damage
Received in revised form 7 April that progresses before the first clinical signs of DR appear. Reduction of the inner neuro-
2018 retinal layer thickness on macular optical coherence tomography, reduced contrast
Accepted 9 April 2018 sensitivity primarily at low spatial frequencies, abnormal results in color vision and
Available online 19 April 2018 microperimetry tests, and a prolonged implicit time recorded by multifocal electroreti-
nography have been proposed for detection of early functional and nonvisible structural
Keywords: neuroretinal changes. Vascular abnormalities such as changes in the retinal vessel caliber,
diabetic retinopathy architectural indices, and blood flow have been investigated to evaluate the early stages of
biomarker DR. The results of optical coherence tomography angiography, retinal vessel oxygen
vascular abnormality saturation patterns, and elevated levels of circulating blood markers and cytokines have
contrast sensitivity been suggested as early signs of DR. Light-based molecular imaging in rodents has been
color vision developed to demonstrate changes in protein expressions in the retinal microvessels as
multifocal electroretinography diagnostic biomarkers. Future clinical studies will examine the safety and efficacy of this
optical coherence tomography approach in humans. We summarize all the studies related to subclinical DR biomarkers.
retinal oximetry ª 2018 Elsevier Inc. All rights reserved.

1. Introduction however, neural retinal damage and clinically invisible

Diabetic retinopathy (DR) is the leading cause of visual
impairment in the working age population worldwide.13 Ac-
cording to a population-based study, DR develops in one-third
of patients with diabetes mellitus (DM), which is clinically
diagnosed by the detection of funduscopic signs of retinal
microvascular complications.45 There is an interval between
the development of DM and the first clinical signs of DR;
microvascular changes progress during the asymptomatic
phase. Therefore, early detection of subclinical DR could
provide timely recognition and management for patients at a
greater risk of DR progression. Currently, the only preventive
strategies at the stages of no or early DR are strict control of
the blood glucose level and other risk factor modifications.
Therapeutic interventions are used only when visible fundu-
scopic microvascular complications have already resulted in

* Corresponding author: Hamid Ahmadieh, MD, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, No 23,
Paidarfard Street, Boostan 9 Street, Pasdaran Avenue, Tehran, Iran 1666673111. Tel: þ98 21 22585952; fax: þ98 21 22590607.
E-mail address: hahmadieh@hotmail.com (H. Ahmadieh).
0039-6257/$ e see front matter ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.survophthal.2018.04.003
602 s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8
irreversible structural changes. The development of agents
that can treat or prevent DR progression at an early stage of
the disease before clinical signs manifest may save the pa-
tient’s vision and significantly reduce the burden of the dis-
ease. Nevertheless, before accessing to the aforementioned
preventive and therapeutic strategies, it is first necessary to
detect the diabetic population with subclinical DR. Identifi-
cation of this subpopulation would influence diagnostic stra-
tegies, disease severity classification, and management
protocols. Furthermore, patients with any signs of subclinical
retinopathy could be followed at shorter intervals.
The utilization of various tests or biomarkers allows
recognition of the functional and structural retinal changes in
patients without DR. Many studies have proposed that neural
damage precedes microvascular abnormalities in DR. Func-
tional retinal abnormalities in patients without obvious fun-
duscopic retinopathy have been shown via alterations in
electroretinography, contrast sensitivity (CS), color vision, and
microperimetry. Furthermore, various structural changes and
vascular abnormalities of the retina have been detected by
using optical coherence tomography (OCT) and OCT angiog-
raphy. Moreover, the use of biomarkers for molecular imaging
has been proposed for the timely detection of subclinical DR
and as a screening tool to predict patients with DM at risk for
the development of retinopathy.
There has been no comprehensive literature review that
includes all relevant articles in this field of research. In this
review, we attempt to describe all studies focused on the
development of subclinical DR biomarkers and how they may
be implemented for routine clinical use and to explore the
possible perspectives for detection of subclinical DR.
2. Retinal structural tests
2.1. Optical coherence tomography
Neuroretinal cell apoptosis can occur as early as 1 month after
the induction of diabetes in experimental models.3 Barber and
colleagues3 recognized equal ganglion cell loss from 2 post-
mortem human retinas with or without retinopathy. In vivo
alteration of the foveal thickness in diabetic patients without
DR was observed using a retinal thickness analyzer.23 The
introduction of spectral-domain OCT allowed the accurate
in vivo measurement of retinal thickness, which enabled
segmentation of the retinal layers. Thinning of the inner
neuroretinal layer has been reported as the primary OCT
finding of diabetic patients with no DR,12,15,26,58,68,80,86
although a few investigations reported different re-
sults.19,76,81 In a longitudinal study, inner retinal layer thin-
ning progressed during the 1-year follow-up.77 The reduction
rate was 0.53 mm per year68 and was correlated with functional
retinal alterations.52 The outer retinal layers were less
affected than the inner layers before DR development.56,86
Tavares Ferriera and coworkers76 suggested that uneven
thinning of the photoreceptor layer was due to cellular
swelling caused by hypoxia and oxidative stress and was
dependent on the duration of the disease. Decreased
choroidal thickness was observed in the preclinical stage of
type 1 and type 2 DM patients using enhanced depth imaging
OCT65,89; however, a recent longitudinal study showed a
thicker choroid in patients who still had no DR after 1 year of
follow-up, probably due to choroidal edema or impaired vessel
autoregulation; the choroid began to thin as DR developed.77 It
is noteworthy that the results of all studies were influenced by
the instrument’s automatic measurement errors and lack of a
uniform definition of no DR. Generally, OCT findings suggest
that retinal neurodegeneration occurs in the early stages of
diabetes before retinal vascular damage manifests. However,
early detection features are currently nonspecific on OCT.
Therefore, OCT has not been used as a reliable instrument for
the early detection of DR.
2.2. OCT angiography
OCT angiography is a new, noninvasive imaging system that
provides visualization of the retinal and choroidal vascula-
ture.32 De Carlo and coworkers17 were the first to use OCT
angiography to demonstrate the increased size of the foveal
avascular zone and the appearance of capillary nonperfusion
in diabetic subjects with no DR compared to controls. Newer
software algorithms provide more accurate quantification of
the volumetric parameters of retinal and choroidal vascula-
ture. Recently, Dimitrova and coworkers18 showed decreased
superficial and deep capillary plexus density, reduced blood
flow, and an increased foveal avascular zone in patients with
type 2 diabetes without retinopathy. Another study showed
decreased deep, but not superficial, capillary density and no
significant difference in the foveal avascular zone size be-
tween patients with type 1 diabetes and controls.11
2.3. Retinal vascular caliber
Changes in the retinal vascular caliber are emerging as a
promising biomarker for the early detection of DR. Given the
prominent role of the effects of DM on retinal blood vessels,
investigators attempted to develop a biomarker to detect or
predict the development of early DR. Studies have demon-
strated that a larger basal vascular caliber was associated with
a higher incidence or progression of DR in both types of DM
after several years of follow-up40,41,60,62; however, the trend of
caliber changes over time appeared to be a more sensitive
indicator of vascular damage than the basal caliber mea-
surement.20,42 Several vascular architectural indices beyond
the vessel caliberdincluding the tortuosity, fractal dimension,
and branching angledhave been suggested as indicators of
early disease14,25; however, the lack of a distinct cutoff for
differentiation of the abnormalities has limited their clinical
application. Vascular autoregulation is impaired at an early
stage of DR. The measurement of vascular caliber or blood
flow changes revealed a weaker normal response of the retinal
vasculature to stimuli. The vasodilatory effect of a flickering
light stimulus was shown to regress in early DR even without
significant alteration of the vascular caliber diameter. Neural
autoregulation of the retinal vessel diameter was shown to be
impaired in patients with no DR by demonstrating decreased
vasodilation induced by a flickering light stimulus.7,49
Lecleire-Collet and coworkers44 found a correlation between
 s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8
the flicker response and abnormalities in the pattern elec-
troretinography, oscillatory potential, and rod function in
patients with no DR and controls. A few studies on patients
with no DR revealed a decreased N95 amplitude in the pattern
electroretinography, reflecting a loss of ganglion cell
activity.10,44,59
Doppler Fourier domain OCT provides information on the
blood flow velocity of the entire retina. With increased accu-
racy and automated calculations, Doppler OCT facilitates the
evaluation of retinal vascular autoregulation in a larger sam-
ple size16; however, despite their potential for noninvasive
direct evaluation of the retinal vessels, none of these bio-
markers has been clinically validated.31
3. Retinal functional tests
3.1. Contrast sensitivity
The alteration of CS in diabetic subjects without retinopathy
has been explored. Changes in CS occur in diabetic patients,
even in those with normal Snellen visual acuity69; however,
no unified algorithm has been generated to define the pattern
of CS alteration in the early stages of DR. Part of this is due to
different test techniques and the conditions of CS measure-
ment in addition to the subjective nature of the test. Exploring
both types of DM, Sokol and coworkers69 detected CS distur-
bance at only a single low spatial frequency in cases of none
insulin-dependent DM without DR. Katz and coworkers36
observed reduced CS at a low spatial frequency in the mes-
opic condition through an investigation of both photopic and
mesopic conditions in patients with no DR; however, other
studies reported significant differences at all spatial fre-
quencies.46,73 Moreover, a longitudinal study revealed that
reduced CS might be reversible at an earlier stage of retinop-
athy using metabolic control.84 Safi and colleagues64 recently
conducted a prospective cross-sectional study showing a
uniform decline at all spatial frequencies in moderate and dim
light. In addition, the measurement of CS at 3 and 6 spatial
frequencies in both lighting conditions could accurately
discriminate diabetics from control subjects.
3.2. Microperimetry
Microperimetry evaluates subjective retinal functional ab-
normalities while directly correlating with fundus observation
and provides early detection of retinal pathology.61 Nittala
and coworkers55 reported reduced foveal sensitivity using the
microperimeter in diabetic patients with no DR compared to
healthy controls. In these cases, the decline of retinal sensi-
tivity using the microperimeter was correlated with decreased
thickness of the nerve fiber layer,82 ganglion cell layereinner
plexiform layer,52 the photoreceptor layer measured by
spectral-domain OCT,83 and the severity of diabetic
neuropathy.53
3.3. Color vision tests
Color vision impairment in diabetic subjects preceding clinical
retinopathy has been established in several population-based
603
cross-sectional studies.24,67,74 Using the Farnsworth-Munsell
100-hue test on 872 diabetics with no DR, 37 participants
were determined to have acquired color deficiency,67 pri-
marily tritanomaly.74 Patients who were female, had
increased intraocular pressure, were older, and had had dia-
betes for a longer period were more likely to be affected.24,74
Furthermore, color vision impairment has been revealed to
be correlated with other functional and structural retinal ab-
normalities and is detectable before any clinical signs of DR
appear.53
3.4. Electroretinography
A multifocal electroretinogram (mfERG) allows a topographic
electrophysiological assessment of the retina and is a superior
evaluation method of macular function. The mfERG results
have demonstrated a significant increase of the implicit time
in eyes with no DR compared to controls.1,5,21,43,66 Bearse and
coworkers5 found decreased uneven retinal distribution of the
implicit time delays in patients with no DR compared to pa-
tients with nonproliferative DR. Abnormalities were more
often found in the inferior retina, probably due to its greater
ischemic susceptibility. They further revealed that the loci of
retina that appeared clinically normal but had functional ab-
normalities remained mostly stable; however, after a 1-year
follow-up, they were more at risk for the development of
microaneurysms compared to zones with a normal baseline
implicit time (odds ratio, 31.4).27 To predict the development
of DR, a model was generated using the abnormal mfERG of
patients with no DR and 6 additional risk factors.29 After a
3-year follow-up, the retinal loci with implicit time delays on
mfERG were 8 times more at risk of DR development.54 In
addition to its use for DR prediction, an increased implicit time
in mfERG could be considered an outcome measure and could
be used to evaluate the efficacy of therapeutic agents for the
prevention of retinopathy development.4 The interocular
spatial correspondence of abnormalities in adolescents with
type 1 DM without retinopathy also facilitates comparative
interventional trials focused on no DR.43 In patients with DR,
the implicit time delay of retinal loci without clinical signs of
retinopathy was positively correlated with the severity of
DR.39 In addition to latency, the mfERG amplitude has also
been shown to decline in patients with no DR. However, it is a
less consistent finding than the implicit time delay,75,79 due to
higher intersubject variability and the requirement need for
more extensive retinal cellular damage to be detectable.4
Therefore, more investigations are needed to clarify how it
affects the early stage of DR.
A standard electroretinography assesses the electrophysi-
ological response of the entire retina to a light stimulus and
includes 5 classic responses. Among them, oscillatory poten-
tials representing feedback interactions of the inner retinal
cells, primarily amacrine cells, are more related to ischemic
retinal conditions; however, it is also altered at the no DR
stage.9,48 Oscillatory potential abnormalities were noticed in
the presence of an intact blood-retinal barrier in patients with
no DR, suggesting early functional changes before the
appearance of vasculopathy.90 Bearse and coworkers6 found
that 25% of patients with no DR had abnormalities of the
enhanced multifocal oscillatory potentials.
604 s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8
Several studies performed visual-evoked potential on
participants with insulin-dependent DM without DR. They
found a significantly progressive reduction in the P100
amplitude and increased latency compared to healthy vol-
unteers2,34 in both basal and post-photostress conditions,57
which was correlated with glycated hemoglobin.50 The
reduction reflected early neurodegeneration in the preclinical
stage of DR.
3.5. Retinal oximetry
Oxygen metabolism is believed to be altered in the retinal
vessels of diabetic patients.28 In the early stages of diabetes,
abnormalities in microvascular chorioretinal circulation
result in a decreased flow rate, causing increased oxygen
consumption by the photoreceptors and an increased differ-
ence in arteriovenous oxygen saturation.30 Liu and co-
workers47 showed an increased inner retinal metabolic rate
and a decreased venular oxygen saturation in the absence of
structural retinovascular damage of diabetic mice compared
with controls. There were no differences in arterial oxygen
saturation or blood flow; however, another study demon-
strated higher arterial and venous oxygen saturation in retinal
circulation in patients with no DR.38 Using hyperspectral
computed tomographic imaging spectroscopy, Kashani and
coworkers35 revealed decreased arterial hemoglobin and
increased venular oxygen saturation in the early stage of
diabetes. Part of this discrepancy may be due to the use of
different methods to measure oxygen saturation. When
magnetic resonance imaging retinal oximetry was also used
as a screening tool for early DR detection, after induced hy-
perventilation the oxygen saturation of diabetic subjects
decreased much earlier than that of control subjects.78,88
4. Molecular biomarkers
Molecular biomarkers in blood or local tissues can be an in-
dicator of either pathology or a biological process. Many of
these biomarkers are evaluated based on their contributory
role in DR pathogenesis. Many studies have investigated
various biomarkers at different stages of DR. However, this
review was confined to biomarkers of significant value to
diabetic patients in the preclinical stage of retinopathy
compared with healthy controls.
Advanced glycation end products are nonenzymatic sugar-
binding products that play a critical role in the development of
microvascular complications in DM.33 Advanced glycation end
product binding to the receptor increases in diabetes and ac-
tivates the production of proinflammatory cytokines.70
Studies have found a significantly increased level of
advanced glycation end products, particularly N-epsilon car-
boxymethyl lysine, in subjects with no DR compared to
healthy subjects.8,51 The level of serum advanced glycation
end product was positively correlated with the severity of DR.
N-epsilon carboxymethyl lysine was suggested as an inde-
pendent predictor for the development of DR in addition to
blood glucose and glycated hemoglobin.8,51
Vascular endothelial growth factor is a principal mediator
secreted by the endothelium in response to ischemia that
promotes vessel permeability and neovascularization. Serum
vascular endothelial growth factor levels were investigated at
different stages of DR compared to healthy controls. The
levels were significantly elevated in patients with no DR and
showed an increased pattern as the severity of DR increased.
Therefore, it might be useful for the detection of diabetic pa-
tients at risk of retinopathy.
As inflammation contributes to the pathogenesis of DR,
various biomarkers for the early detection of DR have been
investigated.87 Vujosevic and coworkers85 found significant
increases in the levels of inflammatory cytokines, particularly
interferon gamma, interleukin-1a, interleukin-3, and mono-
cyte chemotactic proteine2 in diabetic patients with no reti-
nopathy compared to controls. Kaviarasan and coworkers37
suggested that the decreased levels of the anti-inflammatory
compounds lipoxin A4 and brain-derived neurotrophic fac-
tor in diabetic patients compared to controls could be a po-
tential indicator of DR.
Advances in retinal molecular imaging facilitate the visu-
alization of diagnostic target markers using combined mo-
lecular and imaging techniques for the early detection of DR
with a high sensitivity and specificity. Therefore, the molec-
ular expression of different indicators can be quantified
noninvasively even at a low level.72 Sun and coworkers71
revealed increased expression of vascular endothelial
growth factor receptore2 in the retinal capillary endothelia of
diabetic rats compared to controls. This finding was clinically
relevant; vascular endothelial growth factor receptore2 was
higher in retinal tissues of diabetic patients than in normal
age-matched controls.72 Recently, Frimmel and coworkers22
quantified the expression of retinal endothelial a-intercel-
lular adhesion molecule-1 expression using confocal scanning
laser ophthalmoscopy in an experimental model of type 1
diabetes. These studies suggest that a-intercellular adhesion
moleculee1 and vascular endothelial growth factor
receptore2 could serve as diagnostic biomarkers for early
detection of DR. However, human safety and efficacy clinical
trials are needed to establish these molecules as biomarkers
for early detection of DR. At the same time, the imaging sys-
tems are necessary to be improved and optimized (Fig. 1).63
5. Conclusion
This review highlights the variety of research protocols for the
early detection of DR. In general, all studies indicate that the
signs at an early stage of retinopathy may progress even
without visible clinical signs of retinopathy. Therefore,
because of the evidence of functional and structural damage,
the timely detection of DR is necessary. Although there are
considerable efforts in progress to develop methods for the
early detection of DR, none of the current techniques has been
shown to have a solid predictive value. Diagnostic algorithms
and management protocols are still based on funduscopic
examinations, although microvascular complications may
cause irreversible retinal damage before DR becomes detect-
able. The affordability of these diagnostic tests for the general
population, their unknown accuracy without an established
gold standard test at the no DR stage, and the lack of
 s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8 605

Fig. 1 e Schematic of the molecular imaging approach to visualize expression of VEGFR-2 in the retinal microvessels of
diabetic animals. The Hafezi-Moghadam laboratory developed custom-designed fluorophore-laden imaging probes that
target specific molecules in the endothelium of retinal microvessels. VEGFR-2 was shown to be significantly higher in
retinas of diabetic animals in vivo when compared with normal controls.22,71 This approach to detect individual molecules
in the retina lends itself for translation to patients pending safety and efficacy trials and the optimization of the imaging
modalities.63 VEGFR-2 [ vascular endothelial growth factor receptor-2.

longitudinal trials to define predictability prevent the use of

these diagnostic modalities in routine clinical practice at Acknowledgments
present.
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
6. Literature search

A literature search of PubMed and Google Scholar was con- references

ducted in July 2017. Articles published in peer-reviewed jour-
nals on the early detection of DR were included. The search
used the following key words: diabetic retinopathy and early
detection; no diabetic retinopathy and early detection and
DM; without diabetic retinopathy and early detection and DM.
Full articles or their abstracts that were written in English
were included. Publications cited in the references that were
relevant to our subject were also selected. After reviewing the
abstracts, we excluded the studies not directly related to our
topic, including articles that primarily focused on the middle
or late stages of DR.
7. Disclosures
The authors report no commercial or proprietary interest in
any product or concept discussed in this article.
1. Adhikari P, Marasini S, Sah RP, et al. Multifocal
electroretinogram responses in Nepalese diabetic patients
without retinopathy. Doc Ophthalmol. 2014;129(1):39e46
2. Anastasi M, Lauricella M, Giordano C, Galluzzo A. Visual
evoked potentials in insulin-dependent diabetics. Acta
Diabetol Lat. 1985;22(4):343e9
3. Barber AJ, Lieth E, Khin SA, et al. Neural apoptosis in the
retina during experimental and human diabetes. Early onset
and effect of insulin. J Clin Invest. 1998;102(4):783e91
4. Bearse MA Jr, Adams AJ, Han Y, et al. A multifocal
electroretinogram model predicting the development of
diabetic retinopathy. Prog Retin Eye Res.
2006;25(5):425e48
5. Bearse MA Jr, Han Y, Schneck ME, Adams AJ. Retinal function
in normal and diabetic eyes mapped with the slow flash
multifocal electroretinogram. Invest Ophthalmol Vis Sci.
2004;45(1):296e304
606 s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8
6. Bearse MA Jr, Han Y, Schneck ME, et al. Local multifocal
oscillatory potential abnormalities in diabetes and early
diabetic retinopathy. Invest Ophthalmol Vis Sci.
2004;45(9):3259e65
7. Bek T, Hajari J, Jeppesen P. Interaction between flicker-
induced vasodilatation and pressure autoregulation in early
retinopathy of type 2 diabetes. Graefes Arch Clin Exp
Ophthalmol. 2008;246(5):763e9
8. Boehm BO, Schilling S, Rosinger S, et al. Elevated serum levels
of N(epsilon)-carboxymethyl-lysine, an advanced glycation
end product, are associated with proliferative diabetic
retinopathy and macular oedema. Diabetologia.
2004;47(8):1376e9
9. Bresnick GH, Korth K, Groo A, Palta M. Electroretinographic
oscillatory potentials predict progression of diabetic
retinopathy. Preliminary report. Arch Ophthalmol.
1984;102(9):1307e11
10. Caputo S, Di Leo MA, Falsini B, et al. Evidence for early
impairment of macular function with pattern ERG in type I
diabetic patients. Diabetes care. 1990;13(4):412e8
11. Carnevali A, Sacconi R, Corbelli E, et al. Optical coherence
tomography angiography analysis of retinal vascular
plexuses and choriocapillaris in patients with type 1 diabetes
without diabetic retinopathy. Acta Diabetol.
2017;54(7):695e702
12. Carpineto P, Toto L, Aloia R, et al. Neuroretinal alterations in
the early stages of diabetic retinopathy in patients with type 2
diabetes mellitus. Eye (Lond). 2016;30(5):673e9
13. Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet.
2010;376(9735):124e36
14. Cheung CY, Tay WT, Mitchell P, et al. Quantitative and
qualitative retinal microvascular characteristics and blood
pressure. J Hypertens. 2011;29(7):1380e91
15. Chhablani J, Sharma A, Goud A, et al. Neurodegeneration in
type 2 diabetes: evidence from spectral-domain optical
coherence tomography. Invest Ophthalmol Vis Sci.
2015;56(11):6333e8
16. Choi W, Baumann B, Liu JJ, et al. Measurement of pulsatile
total blood flow in the human and rat retina with ultrahigh
speed spectral/Fourier domain OCT. Biomed Opt Express.
2012;3(5):1047e61
17. de Carlo TE, Chin AT, Bonini Filho MA, et al. Detection of
microvascular changes in eyes of patients with diabetes but
not clinical diabetic retinopathy using optical coherence
tomography angiography. Retina. 2015;35(11):2364e70
18. Dimitrova G, Chihara E, Takahashi H, et al. Quantitative
retinal optical coherence tomography angiography in
patients with diabetes without diabetic retinopathy. Invest
Ophthalmol Vis Sci. 2017;58(1):190e6
19. Elhabashy SA, Elbarbary NS, Nageb KM, Mohammed MM. Can
optical coherence tomography predict early retinal
microvascular pathology in type 1 diabetic adolescents
without minimal diabetic retinopathy? A single-centre study.
J Pediatr Endocrinol Metab. 2015;28(1-2):139e46
20. Falck A, Laatikainen L. Retinal vasodilation and
hyperglycaemia in diabetic children and adolescents. Acta
Ophthalmol Scand. 1995;73(2):119e24
21. Fortune B, Schneck ME, Adams AJ. Multifocal
electroretinogram delays reveal local retinal dysfunction in
early diabetic retinopathy. Invest Ophthalmol Vis Sci.
1999;40(11):2638e51
22. Frimmel S, Zandi S, Sun D, et al. Molecular imaging of retinal
endothelial injury in diabetic animals. J Ophthalmic Vis Res.
2017;12(2):175e82
23. Fritsche P, van der Heijde R, Suttorp-Schulten MS, Polak BC.
Retinal thickness analysis(RTA): an objective method to
assess and quantify the retinal thickness in healthy controls
and in diabetics without diabetic retinopathy. Retina.
2002;22(6):768e71
24. Gella L, Raman R, Kulothungan V, et al. Impairment of colour
vision in diabetes with no retinopathy: Sankara Nethralaya
Diabetic Retinopathy Epidemiology and Molecular Genetics
Study (SNDREAMS- II, Report 3). PLoS One.
2015;10(6):e0129391
25. Grauslund J, Green A, Kawasaki R, et al. Retinal vascular
fractals and microvascular and macrovascular complications
in type 1 diabetes. Ophthalmology. 2010;117(7):1400e5
26. Gundogan FC, Akay F, Uzun S, et al. Early Neurodegeneration
of the inner retinal layers in type 1 diabetes mellitus.
Ophthalmologica. 2016;235(3):125e32
27. Han Y, Bearse MA Jr, Schneck ME, et al. Multifocal
electroretinogram delays predict sites of subsequent diabetic
retinopathy. Invest Ophthalmol Vis Sci. 2004;45(3):948e54
28. Hardarson SH, Stefansson E. Retinal oxygen saturation is
altered in diabetic retinopathy. Br J Ophthalmol.
2012;96(4):560e3
29. Harrison WW, Bearse MA Jr, Ng JS, et al. Multifocal
electroretinograms predict onset of diabetic retinopathy in
adult patients with diabetes. Invest Ophthalmol Vis Sci.
2011;52(2):772e7
30. Ibrahim MA, Annam RE, Sepah YJ, et al. Assessment of
oxygen saturation in retinal vessels of normal subjects and
diabetic patients with and without retinopathy using Flow
Oximetry System. Quant Imaging Med Surg. 2015;5(1):86e96
31. Ikram MK, Cheung CY, Lorenzi M, et al. Retinal vascular
caliber as a biomarker for diabetes microvascular
complications. Diabetes care. 2013;36(3):750e9
32. Jia Y, Bailey ST, Hwang TS, et al. Quantitative optical
coherence tomography angiography of vascular
abnormalities in the living human eye. Proc Natl Acad Sci U S
A. 2015;112(18):E2395e402
33. Kandarakis SA, Piperi C, Topouzis F, Papavassiliou AG.
Emerging role of advanced glycation-end products (AGEs) in
the pathobiology of eye diseases. Prog Retin Eye Res.
2014;42:85e102
34. Karlica D, Galetovic D, Ivanisevic M, et al. Visual evoked
potential can be used to detect a prediabetic form of diabetic
retinopathy in patients with diabetes mellitus type I. Coll
Antropol. 2010;34(2):525e9
35. Kashani AH, Lopez Jaime GR, Saati S, et al. Noninvasive
assessment of retinal vascular oxygen content among normal
and diabetic human subjects: a study using hyperspectral
computed tomographic imaging spectroscopy. Retina.
2014;34(9):1854e60
36. Katz G, Levkovitch-Verbin H, Treister G, et al. Mesopic foveal
contrast sensitivity is impaired in diabetic patients without
retinopathy. Graefes Arch Clin Exp Ophthalmol.
2010;248(12):1699e703
37. Kaviarasan K, Jithu M, Arif Mulla M, et al. Low blood and
vitreal BDNF, LXA4 and altered Th1/Th2 cytokine balance are
potential risk factors for diabetic retinopathy. Metabolism.
2015;64(9):958e66
38. Khoobehi B, Firn K, Thompson H, et al. Retinal arterial and
venous oxygen saturation is altered in diabetic patients.
Invest Ophthalmol Vis Sci. 2013;54(10):7103e6
39. Kim SJ, Song SJ, Yu HG. Multifocal electroretinogram
responses of the clinically normal retinal areas in diabetes.
Ophthalmic Res. 2007;39(5):282e8
40. Klein R, Klein BE, Moss SE, Wong TY. Retinal vessel caliber
and microvascular and macrovascular disease in type 2
diabetes: XXI: the Wisconsin Epidemiologic Study of Diabetic
Retinopathy. Ophthalmology. 2007;114(10):1884e92
41. Klein R, Klein BE, Moss SE, et al. The relation of retinal vessel
caliber to the incidence and progression of diabetic
 s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8
retinopathy: XIX: the Wisconsin Epidemiologic Study of
Diabetic Retinopathy. Arch Ophthalmol. 2004;122(1):76e83
42. Klein R, Myers CE, Lee KE, et al. Changes in retinal vessel
diameter and incidence and progression of diabetic
retinopathy. Arch Ophthalmol. 2012;130(6):749e55
43. Laron M, Bearse MA Jr, Bronson-Castain K, et al. Interocular
symmetry of abnormal multifocal electroretinograms in
adolescents with diabetes and no retinopathy. Invest
Ophthalmol Vis Sci. 2012;53(1):316e21
44. Lecleire-Collet A, Audo I, Aout M, et al. Evaluation of retinal
function and flicker light-induced retinal vascular response in
normotensive patients with diabetes without retinopathy.
Invest Ophthalmol Vis Sci. 2011;52(6):2861e7
45. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic
retinopathy, diabetic macular edema and related vision loss.
Eye Vis (Lond). 2015;2:17
46. Liska V, Dostalek M. Are contrast sensitivity functions
impaired in insulin dependent diabetics without diabetic
retinopathy? Acta Med (Hradec Kralove). 1999;42(4):133e8
47. Liu W, Wang S, Soetikno B, et al. Increased retinal oxygen
metabolism precedes microvascular alterations in type 1
diabetic mice. Invest Ophthalmol Vis Sci. 2017;58(2):981e9
48. Luu CD, Szental JA, Lee SY, et al. Correlation between retinal
oscillatory potentials and retinal vascular caliber in type 2
diabetes. Invest Ophthalmol Vis Sci. 2010;51(1):482e6
49. Mandecka A, Dawczynski J, Vilser W, et al. Abnormal retinal
autoregulation is detected by provoked stimulation with
flicker light in well-controlled patients with type 1 diabetes
without retinopathy. Diabetes Res Clin Pract. 2009;86(1):51e5
50. Mariani E, Moreo G, Colucci GB. Study of visual evoked
potentials in diabetics without retinopathy: correlations with
clinical findings and polyneuropathy. Acta Neurol Scand.
1990;81(4):337e40
51. Mishra N, Saxena S, Shukla RK, et al. Association of serum
N(epsilon)-Carboxy methyl lysine with severity of diabetic
retinopathy. J Diabet Complications. 2016;30(3):511e7
52. Montesano G, Gervasoni A, Ferri P, et al. Structure-function
relationship in early diabetic retinopathy: a spatial
correlation analysis with OCT and microperimetry. Eye
(Lond). 2017;31(6):931e9
53. Neriyanuri S, Pardhan S, Gella L, et al. Retinal sensitivity
changes associated with diabetic neuropathy in the absence
of diabetic retinopathy. Br J Ophthalmol. 2017;101(9):1174e8
54. Ng JS, Bearse MA Jr, Schneck ME, et al. Local diabetic
retinopathy prediction by multifocal ERG delays over 3 years.
Invest Ophthalmol Vis Sci. 2008;49(4):1622e8
55. Nittala MG, Gella L, Raman R, Sharma T. Measuring retinal
sensitivity with the microperimeter in patients with diabetes.
Retina. 2012;32(7):1302e9
56. Ozkaya A, Alkin Z, Karakucuk Y, et al. Thickness of the retinal
photoreceptor outer segment layer in healthy volunteers and
in patients with diabetes mellitus without retinopathy,
diabetic retinopathy, or diabetic macular edema. Saudi J
Ophthalmol. 2017;31(2):69e75
57. Parisi V, Uccioli L, Monticone G, et al. Visual evoked potentials
after photostress in insulin-dependent diabetic patients with
or without retinopathy. Graefes Arch Clin Exp Ophthalmol.
1994;232(4):193e8
58. Park HY, Kim IT, Park CK. Early diabetic changes in the nerve
fibre layer at the macula detected by spectral domain optical
coherence tomography. Br J Ophthalmol. 2011;95(9):1223e8
59. Prager TC, Garcia CA, Mincher CA, et al. The pattern
electroretinogram in diabetes. Am J Ophthalmol.
1990;109(3):279e84
60. Rogers SL, Tikellis G, Cheung N, et al. Retinal arteriolar caliber
predicts incident retinopathy: the Australian Diabetes,
Obesity and Lifestyle (AusDiab) study. Diabetes care.
2008;31(4):761e3
607
61. Rohrschneider K, Bultmann S, Springer C. Use of fundus
perimetry (microperimetry) to quantify macular sensitivity.
Prog Retin Eye Res. 2008;27(5):536e48
62. Roy MS, Klein R, Janal MN. Retinal venular diameter as an
early indicator of progression to proliferative diabetic
retinopathy with and without high-risk characteristics in
African Americans with type 1 diabetes mellitus. Arch
Ophthalmol. 2011;129(1):8e15
63. Russmann C, Amiji MM. Molecular imaging of subclinical
diabetic retinopathy. J Ophthalmic Vis Res. 2017;12(2):129e31
64. Safi S, Rahimi A, Raeesi A, et al. Contrast sensitivity to spatial
gratings in moderate and dim light conditions in patients
with diabetes in the absence of diabetic retinopathy. BMJ
Open Diabetes Res Care. 2017;5(1)
65. Shen ZJ, Yang XF, Xu J, et al. Association of choroidal
thickness with early stages of diabetic retinopathy in type 2
diabetes. Int J Ophthalmol. 2017;10(4):613e8
66. Shimada Y, Li Y, Bearse MA Jr, et al. Assessment of early
retinal changes in diabetes using a new multifocal ERG
protocol. Br J Ophthalmol. 2001;85(4):414e9
67. Shoji T, Sakurai Y, Sato H, et al. Do type 2 diabetes patients
without diabetic retinopathy or subjects with impaired
fasting glucose have impaired colour vision? The Okubo Color
Study Report. Diabet Med. 2011;28(7):865e71
68. Sohn EH, van Dijk HW, Jiao C, et al. Retinal
neurodegeneration may precede microvascular changes
characteristic of diabetic retinopathy in diabetes mellitus.
Proc Natl Acad Sci U S A. 2016;113(19):E2655e64
69. Sokol S, Moskowitz A, Skarf B, et al. Contrast sensitivity in
diabetics with and without background retinopathy. Arch
Ophthalmol. 1985;103(1):51e4
70. Stem MS, Gardner TW. Neurodegeneration in the
pathogenesis of diabetic retinopathy: molecular mechanisms
and therapeutic implications. Curr Med Chem.
2013;20(26):3241e50
71. Sun D, Nakao S, Xie F, et al. Molecular imaging reveals
elevated VEGFR-2 expression in retinal capillaries in diabetes:
a novel biomarker for early diagnosis. FASEB J.
2014;28(9):3942e51
72. Sun D, Nakao S, Xie F, et al. Superior sensitivity of novel
molecular imaging probe: simultaneously targeting two types
of endothelial injury markers. FASEB J. 2010;24(5):1532e40
73. Sun TS, Zhang MN. Characters of contrast sensitivity in
diabetic patients without diabetic retinopathy: Zhonghua Yan
Ke Za Zhi. 2012;48(1):41e6
74. Tan NC, Yip WF, Kallakuri S, et al. Factors associated with
impaired color vision without retinopathy amongst people
with type 2 diabetes mellitus: a cross-sectional study. BMC
Endocr Disord. 2017;17(1):29
75. Tan W, Wright T, Dupuis A, et al. Localizing functional
damage in the neural retina of adolescents and young adults
with type 1 diabetes. Invest Ophthalmol Vis Sci.
2014;55(4):2432e41
76. Tavares Ferreira J, Alves M, Dias-Santos A, et al. Retinal
neurodegeneration in diabetic patients without diabetic
retinopathy. Invest Ophthalmol Vis Sci. 2016;57(14):6455
77. Tavares Ferreira J, Proenca R, Alves M, et al. Retina and
choroid of diabetic patients without observed retinal vascular
changes: a longitudinal study. Am J Ophthalmol.
2017;176:15e25
78. Trick GL, Edwards P, Desai U, Berkowitz BA. Early
supernormal retinal oxygenation response in patients
with diabetes. Invest Ophthalmol Vis Sci. 2006;47(4):
1612e9
79. Tyrberg M, Ponjavic V, Lovestam-Adrian M. Multifocal
electroretinography (mfERG) in insulin dependent diabetics
with and without clinically apparent retinopathy. Doc
Ophthalmol. 2005;110(2-3):137e43
608 s u r v e y o f o p h t h a l m o l o g y 6 3 ( 2 0 1 8 ) 6 0 1 e6 0 8
80. van Dijk HW, Kok PH, Garvin M, et al. Selective loss of inner
retinal layer thickness in type 1 diabetic patients with
minimal diabetic retinopathy. Invest Ophthalmol Vis Sci.
2009;50(7):3404e9
81. van Dijk HW, Verbraak FD, Kok PH, et al. Decreased
retinal ganglion cell layer thickness in patients with
type 1 diabetes. Invest Ophthalmol Vis Sci. 2010;51(7):3660e5
82. Verma A, Raman R, Vaitheeswaran K, et al. Does neuronal
damage precede vascular damage in subjects with type 2
diabetes mellitus and having no clinical diabetic retinopathy?
Ophthalmic Res. 2012;47(4):202e7
83. Verma A, Rani PK, Raman R, et al. Is neuronal dysfunction an
early sign of diabetic retinopathy? Microperimetry and
spectral domain optical coherence tomography (SD-OCT)
study in individuals with diabetes, but no diabetic
retinopathy. Eye (Lond). 2009;23(9):1824e30
84. Verrotti A, Lobefalo L, Petitti MT, et al. Relationship between
contrast sensitivity and metabolic control in diabetics with
and without retinopathy. Ann Med. 1998;30(4):369e74
85. Vujosevic S, Micera A, Bini S, et al. Proteome analysis of
retinal glia cells-related inflammatory cytokines in the
aqueous humour of diabetic patients. Acta Ophthalmol.
2016;94(1):56e64
86. Vujosevic S, Midena E. Retinal layers changes in human
preclinical and early clinical diabetic retinopathy support
early retinal neuronal and Muller cells alterations. J Diabetes
Res. 2013;2013:905058
87. Vujosevic S, Simo R. Local and systemic inflammatory
biomarkers of diabetic retinopathy: an integrative approach.
Invest Ophthalmol Vis Sci. 2017;58(6):BIO68e75
88. Yang Y, Zhu XR, Xu QG, et al. Magnetic resonance imaging
retinal oximetry: a quantitative physiological biomarker
for early diabetic retinopathy? Diabet Med.
2012;29(4):501e5
89. Yolcu U, Cagiltay E, Toyran S, et al. Choroidal and macular
thickness changes in type 1 diabetes mellitus patients
without diabetic retinopathy. Postgrad Med.
2016;128(8):755e60
90. Yoshida A, Kojima M, Ogasawara H, Ishiko S. Oscillatory
potentials and permeability of the blood-retinal barrier in
noninsulin-dependent diabetic patients without retinopathy.
Ophthalmology. 1991;98(8):1266e71