Diabetic retinopathy historical perspective
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rohan Bir Singh, M.B.B.S.[2]
Historical Perspective
Although diabetes was a well-known disease as from the 2nd century AD, no clinician attempted to link this endocrine disorder with eye-pathology before the middle of the 19th century. In 1846, the French ophthalmologist and Professor of Hygiene in Paris, Appolinaire Bouchardat (1806-1886), reported the development of visual loss in the absence of cataract in diabetics. This was partly reversible and in most cases improvement was associated with better control of diabetes. A few years later, François Tavignot made similar observations.[1] However, no histopathological specimens were examined and the implication of macular disease in diabetes remained tentative until the invention of the ophthalmoscope.
Jäger had inexhaustible patience and exemplary precision in ophthalmoscopy and, in illustrating his findings, meticulously incorporated the smallest details into his pictures. He used the newly developed direct ophthalmoscope in order to produce one of the first atlases containing 21 colour plates of fundus paintings, which were drawn after 20-40 clinical sessions per patient. He described ‘roundish’ or oval, yellowish spots and full or partial thickness extravasations through the retina in the macular region of a diabetic patient.[1] His findings were controversial at the time and Albrecht von Graefe (1828-1870) claimed that there was no proof of a cause-effect relationship between diabetes and retinal complications. Von Graefe’s scepticism was adopted by many of his colleagues, with the exception of Louis Desmarres (1810-1882) in 1858.
No further evidence was presented until 1869, when Henry Noyes (1832-1900) published an article in the USA supporting the link between diabetes mellitus and maculopathy. His observations were confirmed in 1872 by Edward Nettleship (1845-1913) in London, who expanded on this theme in his paper entitled ‘On oedema or cystic disease of the retina’ and presented the first histopathological proof of a cystoid degeneration of the macula in diabetic patients.Five years later, Nettleship published another article with Sir Steven Mackenzie (1791-1868), which described in detail the abnormal retinal changes induced by diabetes. n 1876, Wilhelm Manz (1833-1911) published his seminal paper on ‘Retinitis proliferans’ containing several drawings of fibrovascular degeneration of the optic disc and vitreoretinal adhesions in the retina. Fourteen years later, in 1890, Julius Hirschberg (1843-1925) classified diabetic retinopathy into four types (retinitis centralis punctuate, haemorrhagic form, retinal infarction, and haemorrhagic glaucoma), thus describing the full natural history of diabetic retinopathy. The descriptive term, diabetic retinitis, though erroneous since the disease is not of inflammatory origin, continued to be used for several years.
At the beginning of the 20th century there was still the unresolved debate as to whether macular changes were directly related to diabetes or whether they were caused by atherosclerosis and hypertension. Arthur James Ballantyne (1876-1954) of Glasgow suggested that diabetic retinopathy represents a unique form of vasculopathy and his work showed for the first time the role of capillary wall alterations in the development of diabetic retinopathy, as well as the presence of deep waxy exudates in the outer plexiform layer.
Today the retinal manifestations of diabetes are classified as Early Non-proliferative Diabetic Retinopathy, Advanced Non-proliferative Diabetic Retinopathy, and Proliferative Diabetic Retinopathy.