participants shows, the Framingham risk scores significantly underestimate the absolute risk of cardiovascular disease in diabetic populations (95). Clearly, there is need to search for more specific predictor for cardiovascular disease risk in people with diabetes. There is now good evidence that retinopathy, reliably detectable from retinal photographs, is an early marker of subclinical vascular disease and a strong independent predictor of clinical cardiovascular events. Thus, incorporating retinopathy into the currently available risk prediction tools (98, 99) may refine cardiovascular disease prediction in asymptomatic persons with diabetes. Retinopathy has already been proposed to be used in clinical settings to guide preoperative assessment and counseling of diabetic patients planning for elective cardiac revascularization procedures (72–76).

Apart from people with diabetes, there is emerging evidence that classical signs of early “diabetic” retinopathy (e.g., microaneurysms, retinal hemorrhages, and cotton wool spots) are relatively common even in people without clinically diagnosed diabetes (100, 101). Studies have reported high prevalence (up to 14%) and incidence (6–10%) rates of these retinopathy lesions in nondiabetic general populations (102, 103). Retinopathy signs in people without diabetes have also been associated with an increased risk of stroke (39, 43, 104), ischemic heart disease (105), congestive heart failure (62), and impaired renal function (86, 87); and may also indicate a greater risk of hypertension and an excess risk of future diabetes (106), particularly if there is a family history of diabetes (107, 108). These “nondiabetic” retinopathy signs may therefore reflect masked abnormalities in glucose metabolism, blood pressure regulation, and other processes. Additional research is needed to delineate further the pathogenic basis and clinical significance of retinopathy signs in nondiabetic individuals.

CONCLUSION

Diabetic retinopathy is a common microvascular complication in the eyes of diabetic individuals (109). Besides its serious threat to vision, the presence of retinopathy also signifies an excess risk of morbidity and mortality attributable to systemic microand macrovascular disease. It is increasingly clear that retinopathy may reflect diabetic vascular injury not only in the eyes but also in the other organs such as the brain (stroke), heart (coronary heart disease, heart failure), and kidneys (renal dysfunction). Studying these retinopathy lesions provides a unique channel to further our understanding of the pathogenesis of various systemic diseases in diabetes, and early detection of retinopathy may also offer a means to implement therapeutic measures that can prevent the development or halt the progression of these systemic complications. For ophthalmologists and other eye care providers, it is therefore important not to overlook the broader clinical implications of retinopathy beyond the eyes of their diabetic patients.

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