Retinal and coronary imaging in type 1 diabetes: links between retinopathy and subclinical cardiovascular disease

Cardiovascular disease (CVD) remains the leading cause of premature morbidity and mortality in individuals with type 1 diabetes mellitus (T1DM), despite advances in glycemic management and cardiovascular prevention. Conventional cardiovascular risk assessment may underestimate risk in T1DM, particularly among younger asymptomatic individuals, highlighting the need for markers of early vascular injury. Diabetic retinopathy (DR), a microvascular complication of T1DM, is increasingly recognized as a marker of systemic vascular dysfunction rather than an isolated ocular disorder. Non-invasive retinal visualization may provide insight into vascular and atherosclerotic disease. This mini-review summarizes evidence linking DR with subclinical coronary artery disease (CAD) and cardiovascular outcomes in T1DM, focusing on coronary artery calcium (CAC) and coronary computed tomography angiography (CCTA). Observational and longitudinal studies consistently link DR severity with CAC burden, coronary plaque burden, silent CAD, and cardiovascular outcomes, independent of traditional risk factors. Albuminuria and diabetic kidney disease may provide complementary evidence of a broader microvascular phenotype associated with cardiovascular risk. Advances in retinal imaging, including optical coherence tomography angiography and artificial intelligence-based oculomics, support the role of retinal biomarkers in cardiovascular risk prediction. CAC scoring remains valuable for detecting subclinical coronary atherosclerosis, while CCTA characterizes calcified and non-calcified plaque. Emerging evidence suggests that integrating retinal and microvascular markers with coronary imaging may improve identification of asymptomatic individuals at increased cardiovascular risk and support intervention. Although data are observational and prospective validation is required, multimodal strategies combining clinical risk factors, retinal biomarkers, albuminuria, CAC, and CCTA may enhance cardiovascular risk stratification in T1DM.