Preproliferative Diabetic Retinopathy (PPDR): Causes, Symptoms, and Management

What is Preproliferative Diabetic Retinopathy (PPDR)?

Preproliferative diabetic retinopathy (PPDR) is an advanced stage of diabetic retinal damage that occurs before the development of proliferative diabetic retinopathy (PDR). Retinal blood vessels become increasingly abnormal at this stage, leading to a higher risk of vision loss if left untreated.

Regular monitoring through retinal imaging and early intervention can help prevent progression to sight-threatening complications.

Symptoms and Signs of PPDR

PPDR often has no noticeable symptoms in its early stages. However, some people may experience:

  • Mild vision disturbances
  • Increased floaters
  • Difficulty seeing in dim light

Many of the changes in PPDR can only be detected through an ophthalmic examination, which is why regular eye screening is essential for people with diabetes.

How is PPDR Diagnosed?

Ophthalmologists use advanced imaging techniques to detect PPDR:

  1. Retinal Photography
    High-resolution retinal imaging is used to monitor disease progression over time.
  2. Optical Coherence Tomography (OCT)
    OCT provides detailed cross-sectional images of the retina to assess swelling or structural damage.
  3. Fluorescein Angiography (FA)
    A fluorescent dye is injected into the bloodstream, and images of the retina are taken to identify blood vessel leakage, ischemia, and abnormal vessel growth.

Key Retinal Changes in PPDR

PPDR is characterized by vascular abnormalities that signal worsening diabetic retinopathy.

1. Intraretinal Microvascular Abnormalities (IRMA)

  • Irregularly shaped, dilated blood vessels form in response to poor circulation.
  • Unlike new vessel growth in PDR, IRMA remains within the retina.

2. Cotton Wool Spots

  • White, fluffy lesions appear where the blood supply is blocked, leading to nerve fiber damage.
  • These spots indicate areas of retinal ischemia.

3. Venous Beading and Looping

  • Abnormal twisting and bulging of retinal veins suggest increased vascular stress.
  • Venous beading is a strong predictor of progression to PDR.

4. Retinal Hemorrhages and Microaneurysms

  • Dot and blot hemorrhages appear as small areas of bleeding within the retina.
  • Microaneurysms are tiny, bulging weak spots in the blood vessels that may leak fluid.

Risk of Progression to Proliferative Diabetic Retinopathy (PDR)

Without proper management, PPDR can progress to proliferative diabetic retinopathy (PDR), where fragile new blood vessels form on the retina. These vessels can rupture and bleed, leading to:

  • Vitreous hemorrhage (bleeding inside the eye)
  • Retinal detachment
  • Severe vision loss or blindness

Treatment and Prevention Strategies

While there is no direct treatment for preproliferative diabetic retinopathy (PPDR) itself, proactive management strategies can significantly reduce the risk of progression to proliferative diabetic retinopathy (PDR):

Optimize Blood Sugar Control

  • Keeping HbA1c levels below 7% is crucial in reducing the risk of retinopathy progression.
  • Intensive glycemic control has been shown to decrease the onset and progression of diabetic retinopathy.

Manage Blood Pressure and Cholesterol

  • High blood pressure and dyslipidemia contribute to retinal damage.
  • Blood pressure should be maintained at a target of below 140/90 mmHg, or as recommended by your healthcare provider.

Regular Eye Exams

  • People with PPDR should undergo dilated eye exams every 3-6 months to detect early signs of progression.

Early Treatment for High-Risk Cases

  • Laser Therapy (Panretinal Photocoagulation – PRP) can help reduce the risk of severe vision loss by preventing neovascularization.
  • Anti-VEGF Injections (e.g., Ranibizumab, Aflibercept) may be recommended for patients with diabetic macular edema or high-risk PDR features.

Nutritional and Supplementary Approaches

Fish Oil (Omega-3 Fatty Acids)

  • Recommended Dosage: The American Heart Association recommends 1,000 mg of EPA and DHA daily for cardiovascular and general anti-inflammatory benefits. Some studies suggest 2,000-3,000 mg per day may be beneficial for specific retinal health, but consultation with a healthcare provider is essential.
  • Potential Benefits: May reduce retinal inflammation, improve blood flow, and slow the progression of diabetic retinopathy.
  • How to Take: Fish oil supplements are typically taken in capsule form, with food to enhance absorption and reduce the risk of gastrointestinal discomfort.
  • Precautions: High doses may increase the risk of bleeding, especially in individuals on anticoagulant therapy.

Study Reference:

  • Diabetic Retinopathy and Omega-3 Fatty Acids: A study published in Investigative Ophthalmology & Visual Science (2020) found that higher dietary intake of omega-3 fatty acids was associated with a reduced risk of progression to PDR. (Source: “Omega-3 Fatty Acid Intake and Progression of Diabetic Retinopathy,” IOVS, 2020).

Rutin (Flavonoid)

  • Recommended Dosage: Clinical studies suggest a 500 mg to 1,500 mg daily, divided into two or three doses. However, the optimal dose for diabetic retinopathy is explicitly not yet established.
  • Capillary Health: Rutin strengthens blood vessels, potentially reducing microaneurysms and retinal hemorrhages.
  • How to Take: Rutin is available as a dietary supplement and can be obtained through apples, citrus fruits, buckwheat, and tea.
  • Precautions: Rutin is generally considered safe, but excessive intake may cause digestive discomfort. People on blood thinners should exercise caution, as it can affect blood clotting.

Study Reference:

  • Effects of Rutin on Retinal Health: Research in Journal of Ethnopharmacology (2021) demonstrated that rutin’s antioxidant and vasoprotective properties might help reduce the progression of diabetic retinopathy. (Source: “Rutin and Retinal Microvascular Protection,” Journal of Ethnopharmacology, 2021).

Consultation and Safety

  • Before adding fish oil or rutin supplements to your regimen, consult your healthcare provider to ensure safety and appropriate dosing.
  • These supplements should complement, not replace, evidence-based treatments and management strategies for diabetic retinopathy.

Conclusion

Preproliferative diabetic retinopathy (PPDR) is a serious warning sign of worsening diabetic eye disease. Strict diabetes management and regular ophthalmic evaluations are key to preserving vision and preventing complications.

If you have diabetes, ensure you schedule routine eye exams to detect retinal changes before they lead to vision loss. Try to catch eye complications as early as possible. 

Explore More on Eye Complications

This article is part of a series covering different eye complications, their development, and what can be done to prevent or treat them. Click the links below to learn more: