Advances in diagnosing and treating diabetic retinopathy

Diabetic retinopathy has traditionally been defined as a microvascular complication of diabetes mellitus; however, advances in retinal imaging, digital technologies and mechanistic insights have challenged this narrow view. Increasing evidence indicates that neuronal and glial dysfunction and degeneration, neuroinflammation, capillary non-perfusion and metabolic dysregulation can occur early in the disease process and can precede or coexist with clinically apparent vascular abnormalities. These insights support the emerging concept of diabetic retinal disease (DRD), which encompasses the full spectrum of diabetes mellitus-related retinal pathology, with or without visible microvascular lesions. In this Review, we summarize the evolution of disease classification and advances made within the past 10 years in diagnostic imaging that enable more precise phenotyping and risk stratification of DRD. We also present a framework for a digitally enabled care pathway spanning screening, diagnosis, treatment and post-treatment follow-up. Finally, we discuss current therapies alongside emerging preventive and personalized treatment strategies that target both vascular and neuroretinal components across the full DRD disease continuum.