Adaptive Optics Imaging in Diabetic Retinopathy: A Comprehensive Review.

Abstract

Objective: Diabetic retinopathy (DR), a major diabetes complication, is the fifth leading cause of global blindness and moderate-to-severe visual impairment. DR is categorized into non-proliferative and proliferative forms, with the latter involving neovascularization. Adaptive optics (AO) imaging provides high-resolution, in vivo visualization of retinal microstructures, offering enhanced insight into disease pathology.

Methods: A comprehensive PubMed search was conducted for studies published before August 1, 2025, using the keywords "diabetic retinopathy" and "adaptive optics". The review focused on studies assessing cone photoreceptors, retinal vasculature, and clinical signs using AO imaging.

Results: Forty-two studies were included. Many examined cone photoreceptor integrity across DR stages, with or without diabetic macular edema (DME). AO imaging revealed microstructural changes, enabling the correlation of cone metrics with other imaging modalities, including optical coherence tomography angiography, electroretinography, microperimetry, and color vision tests. Several studies analyzed capillary-level vascular alterations and their association with DR severity and DME. Some works have integrated AO data with blood flow assessments using techniques such as laser speckle flowgraphy and AO scanning laser ophthalmoscopy. Lastly, several studies have identified clinical signs related to DR and described their features on AO imaging.

Discussion: Adaptive optics imaging reveals early and progressive alterations in photoreceptors, retinal microvasculature, and clinical signs such as microaneurysms and hard exudates in diabetic retinopathy, supporting its role as a valuable tool for understanding disease mechanisms and guiding early diagnosis and monitoring.

Conclusions: Adaptive optics is a valuable imaging tool that improves understanding of retinal microarchitecture in diabetic retinopathy. It aids diagnosis, monitoring, and prognosis by enabling detailed evaluation of cellular and vascular alterations.