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How to Grade Diabetic Retinopathy

Grading of retinal photographs for clinical decision-making

Non proliferative diabetic retinopathy (NPDR)
Mild Microaneurysms only, in 1 - 3 quadrants
Moderate More than just microaneurysms but less than severe NPDR
Severe Any of the following:
  • Microaneurysms in all 4 quadrants
  • Venous beading in at least 2 quadrants
  • Prominent intraretinal microvascular abnormality (IRMA) in at least 1 quadrant
Proliferative diabetic retinopathy (PDR) Any of the following:
  • Abnormal new vessels (neovascularization)
  • Vitreous haemorrhage
  • Preretinal haemorrhage
Advanced diabetic eye disease Any of the following:
  • Fibrovascular tissue proliferation
  • Retinal dragging
  • Retinal detachment
Diabetic maculopathy Hard exudates at the macula
Retinal thickening at the macula
Non gradeable images Poor quality images
Third order retinal vessel branching not clearly visible

  1. CPG for the Screening of Diabetic Retinopathy, June 2011, MOH/P/PAK/216.11(GU)
  2. Preferred Practice Pattern on Diabetic Retinopathy 2008, American Academy of Ophthalmology

Download “A quick guide to reviewing diabetic retinal photographs” reference card