Asymmetric diabetic retinopathy

Increasing prevalence of diabetes mellitus warrants recognition of factors related to asymmetric diabetic retinopathy (DR). This thematic synthesis based on an iterative literature review conducted in Medline and Google Scholar pertaining to diabetes with coexistent asymmetry of retinopathy included 45 original articles, 21 case reports and series, and 18 review articles from 1965 to 2020. Asymmetric DR is defined as proliferative DR (PDR) in one eye and nonproliferative, preproliferative, background, or no DR in the other eye lasting for at least 2 years. It is observed in 5%-10% of patients with PDR. Associated factors can be divided into (i) vascular: carotid obstructive disease, ocular ischemic syndrome, and retinal vascular diseases; (ii) Inflammatory: uveitis, endophthalmitis, and Fuchs' heterochromic cyclitis; (iii) degenerative: posterior vitreous detachment, high myopia and anisometropia, uveal coloboma, retinal detachment, retinitis pigmentosa, and chorioretinal atrophy and scarring; (iv) cataract surgery and vitrectomy; and (v) miscellaneous: elevated intraocular pressure, glaucoma, amblyopia, retinal detachment, and optic atrophy. The gamut of diagnostic modalities for asymmetric DR includes thorough ocular examination, slit-lamp biomicroscopy, fundus photography, fundus fluorescein angiography, optical coherence tomography, and newer modalities such as ultra-widefield fluorescein angiography and optical coherence tomography angiography, along with a complete systemic evaluation and carotid Doppler studies. The differential diagnosis includes other causes of retinal neovascularization that may present in an asymmetric manner, such as sickle cell retinopathy, retinal vein occlusions, and featureless retina. This review discusses in detail the aforementioned considerations and draws a comprehensive picture of asymmetric DR in order to sensitize ophthalmologists to this important condition.