Diabetic retinopathy (DR) is the main ocular complication of diabetes mellitus and represents a problem with a significant social impact, being one of the main causes of blindness and low vision in working age. Its prevalence, which is around 34% of patients with diabetes, is expected to dramatically increase especially in developing countries.

Specific screening and treatment strategies will therefore be required. In Italy, according to AMD Annals data, 12.9% of patients examined with type 2 diabetes and 22.8% with type 1 diabetes are affected by DR. This complication recognizes as main risk factors the duration of the disease, the level of glycated hemoglobin, hypertension, dyslipidemia, smoking, pregnancy, type 1 diabetes. The first classification of DR was proposed in 1890 and with the knowledge’s progress and different pathological conditions’ characterization, many classification systems of varying complexity have alternated over the decades. The most recent classifications, such as the ETDRS and the ICDR severity scale, are currently in use for the classification, management and monitoring of DR. It is desirable to update these classifications particularly with regard to the inclusion of prognostic elements derived from new retinal imaging systems, the evaluation of non-vascular aspects such as Diabetic Retinal Neurodegeneration (DRN), use of information and biomarkers derived from new imaging modalities, greater consideration for diabetic macular oedema as the main cause of visual impairment caused by DR and finally the prognosis of the condition following the available treatments.

KEY WORDS diabetic retinopathy; macular oedema; classification.

The pathophysiology of diabetic retinopathy is not fully understood even if breakdown of the blood retinal barrier plays the most important role in macular edema. Loss of retinal vascular pericytes, thickening of the vascular endothelium basement membrane and alteration in retinal blood flow represent only few mechanisms in diabetic retinopathy disease. New evidences showed that in addition to vascular mechanism, inflammation and neurodegeneration may contribute in pathophysiology of diabetic retinopathy, opening the chance for new therapeutic targets in the future of diabetic retinopathy treatment.

KEY WORDS pathophysiology, macular edema, vascular pathology, inflammation, retinal neurodegeneration

Diabetic retinopathy is the most common microvascular complication of diabetes and is still an important cause of visual impairment, being able to reach even the most advanced stages of the disease in the almost total absence of symptoms. However, the percentage of patients screened is still too low in our country. This work examines the main existing screening tools, indications and pathways and proposes possible solutions to increase adherence.

KEY WORDS diabetic retinopathy; screening program; diabetes mellitus

Diabetic retinopathy is a leading complication of diabetes. Its prevalence is 30% and if not diagnosed in time can cause important vision loss up to blindness. Systematic screening allows diagnosis of retinopathy in its early forms. Taking care of these patients by ophthalmologists is important to perform a tight control in order to prevent or delay sight threatening diabetic retinopathy. Major technological advancements in imaging over the past decade have improved our understanding and knowledge of diabetic retinopathy and therefore a multimodal approach to imaging has become the standard of care.

Updates to traditional technologies such as digital fundus photography with recent advancements in optical coherence tomography (OCT) and OCT angiography (OCT-A) have provided clinicians with new informations and improved efficiency.

Nowadays digital fundus cameras are the main tools to perform retinopathy screening. In addition, wide-field technologies provide images for monitoring mild non proliferative retinopathy.

Besides the crucial role of OCT, OCT-A is a new non-invasive imaging technique exploring retinal vascularization and its role is essential to detect ischemic retinal areas in the monitoring of mild non proliferative diabetic retinopathy.

KEY WORDS multimodal imaging; mild diabetic retinopathy; optical coherence tomography biomarkers; OCT-angiography.

In the recent decades, therapy of Diabetic Retinopathy (DR) has been enriched with more conservative treatments: laser therapy, aimed at destroying ischemic areas and easing resorption of macular edemas, has been joined by intravitreal injections of anti-angiogenic factors and corticosteroids. Laser therapy is still used nonetheless; surgery is reserved to more advanced and complicated cases. A tight control of diabetes and other systemic factors mostly influence DR evolution; together with a careful prevention pathway aimed to identify early stages, they can effectively reduce therapies’ burden and improve visual prognosis.

KEY WORDS diabetic retinopathy; laser treatment; intravitreal therapy; antiVEGF; corticosteroids; surgery.

Glycemic control management influences the incidence and progression of diabetic retinopathy, which can be limited increasing Time in Range and reducing HbA1c values, the hyperglycemia and hypoglycemia period and glycemic variability.

Intensive glycemic control must be pursued from the onset of diabetes to ensure good metabolic memory and in order to avoid progression to advanced stages of diabetic retinopathy, where effective retinal protection cannot be ensured, even in the presence of optimal glycemic control.

A rapid blood glucose level drop in patients with long-standing poor glycemic control in advanced stages of diabetic retinopathy can lead to retinal damage, which is known as Early Worsening of Diabetic Retinopathy.

A good glycemic balance and therefore protection against diabetic retinopathy, can be obtained through the promotion of healthy lifestyles (proper nutrition, physical activity, sleep hygiene) and drug therapy. Some classes seem to show an overall protective effect (metformin and SGLT2i), while for others a possible negative correlation has been highlighted, such as for Thiazolidinediones with diabetic macular edema and cases of worsening of diabetic retinopathy in advanced stage in patients on GLP1-RA therapy, in association with insulin therapy and in case of long-standing and not well controlled diabetes. For other classes (DPP4i, acarbose, tirzepatide) the data in the literature are still insufficient and mostly conflicting and therefore inconclusive.

KEY WORDS diabetic retinopathy; glycemic control; early worsening of diabetic retinopathy; metabolic memory; anti-hyperglycemic drugs.

Immunoglobulin A (IgA) nephropathy is a common glomerulonephritis, but its treatment remains matter of debate. Renin-angiotensin inhibitors (RAASi) and sodium-glucose co-transporter 2 inhibitors (SGLT2i) are increasingly used because of a better benefit/safety balance in comparison with systemic steroids and immunosuppressive treatments. In this article, we analyze the antiproteinuric effect of a GLP1-RA in a diabetic patient with biopsy-proven nephrotic IgA-related nephropathy. In the patient dulaglutide was added to the previous treatment with angiotensin II receptor antagonists and SGLT2-i. We documented a rapid meaningful reduction of proteinuria which has returned to normal. Considering the beneficial effects of GLP1-RA in diabetes related chronic kidney disease, the present case report supports the notion that these drugs could also represent a beneficial treatment option in IgA nephropathy.

KEY WORDS IgA nephropathy; dulaglutide; DAPA-CKD; EMPA-KIDNEY;
diabetes.