A 47-year-old man presented to our clinic with a complaint of near blur, especially at the computer. He reported a 15-year history of type 2 diabetes with poor control of his blood sugar. He was taking insulin, metformin, and liraglutide injection (Victoza, Novo Nordisk) for his diabetes, and the beta blocker carvedilol for hypertension. His last exam was 2 years ago at a different clinic. Entering acuities were 20/20 OD and 20/25- OS.


Dilated retinal examination revealed multiple scattered dot-blot hemorrhages in his right eye, exudates near the macula, and areas suspicious for intraretinal microvascular abnormalities (IRMA). OCT was normal with no evidence of diabetic macular edema (DME). The patient’s left eye revealed multiple dot-blot hemorrhages with minimal exudates, a prominent area of venous beading inferonasal to the optic nerve head, and likely IRMA nasal to the optic nerve head (Main Figure). OCT revealed mild center-involved DME (Inset).

<p>(Photo captured using the Eidon TrueColor Confocal Scanner (CenterVue))</p>

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(Photo captured using the Eidon TrueColor Confocal Scanner (CenterVue))

The patient was diagnosed with severe nonproliferative diabetic retinopathy (NPDR) in each eye, worse in the left eye. Our retinal service confirmed the diagnosis. A series of intravitreal anti-VEGF injections was recommended for the patient’s left eye, followed by the same for his right eye. A second referral was sent to primary care to help obtain tighter control of his blood sugar.


Ranibizumab (Lucentis, Genentech) and aflibercept (Eylea, Regeneron) are both indicated for the treatment of all forms of diabetic retinopathy (DR) in patients with or without DME. In the RISE and RIDE studies, between 37% and 39% of patients treated with monthly ranibizumab had a 2-step or better improvement in their DR versus 4% to 7% in the sham treatment arm. A subsequent post hoc analysis demonstrated that 78% of patients with moderately severe or severe NPDR had greater than a 2-step regression in DR.1,2

The PANORAMA study evaluated aflibercept in patients with severe or moderately severe NPDR.3 At 100 weeks, 62% of patients treated every 16 weeks achieved a 2-step or greater improvement in DR versus 13% in the sham group.4 Additionally, fewer patients treated with aflibercept progressed to PDR over 52 weeks.


Severe NPDR can be diagnosed using the 4-2-1 rule: dot-blot hemorrhages in all four quadrants, venous beading in two or more quadrants, or marked IRMA in one or more quadrants. Based on information regarding anti-VEGF injections for patients with moderately severe to severe NPDR, this level of retinopathy should be referred to a retina specialist to consider treatment.

Chief, Optometry, Sepulveda VA, North Hills, California
Professor, Southern California College of Optometry at Marshall B. Ketchum University, Fullerton, California
Member, Modern Optometry Editorial Advisory Board
Financial disclosure: Speakers Bureau or Advisory Board (CenterVue, Genentech, Regeneron)