Functional diabetic retinopathy: A new concept to improve management of diabetic retinal diseases

Multifocal functional tests are not routinely performed in diabetic retinopathy (DR) and diabetic macular edema (DME) management. We emphasise their importance and coin the term functional diabetic retinopathy (FDR). We reviewed current guidelines on management of DR/DME, and literature on diabetic retinal neurodegeneration (DRN) and functional deficits in DR/DME. Functional visual loss due to DRN precedes vasculopathy and clinical DR; however, currently the diagnosis and management of DR/DME are based on classical signs of retinal vasculopathy and structural changes shown by funduscopy, fundus photographs, and optical coherence tomography (OCT). Furthermore, DME can mask DRN-based retinal layer thinning by OCT and is focussed on the macular region. The only functional test recommended in national and international guidelines on DR/DME is best-corrected visual acuity, a test of foveal function (<1 % of retina). Multifocal functional tests can objectively characterize both foveal and extrafoveal, localized and global, function. Current recommendations for DR/DME screening are inadequate to detect FDR affecting the greater retina. Early detection of FDR using multifocal functional tests could bring DR/DME management strategies forward enabling prevention of the later stage vision-threatening complications. After all, the end point of patient care is functional outcomes.